METHODS

OF
GAINING SPACE
~ Proximal reduction

~Arch Expansion

~Distalization of molars

~Uprighting of teeth

~Derotation of teeth

~Proclination of teeth

~Extraction
PROXIMAL REDUCTION

~Slenderization, disking or proximal slicing

~Reproximation-selective reduction of mesio-distal width

~Mandibular incisors > maxillary incisors > premolars

~Peck & Peck Index

Tooth selection is based on

~The location of excess tooth material

~The amount of discrepancy

~The thickness of the enamel

~Dental caries potential

~Periodontal considerations
Indications

~ Minimum space requirement(2.5mm-3mm)

~ Boltons tooth material excess

~Mandibular anterior teeth excess

Contraindications

~Susceptibility to dental caries

~Young individual s

~Periodontal compromised situations

~Wear facets etc

Procedure

~Assessing space requirements

~Selecting the teeth & amount of enamel to be reduced

~Enamel reduction
Assessing Space requirements

~ Arch Perimeter Analysis / Careys analysis

~Bolton analysis

Selection of teeth

~Most frequent-mandibular incisors

~Maxillary anterior teeth , if the enamel thickness is sufficient

~IOPA to reveal thickness

~Long cone technique less distortion

~No more than half the thickness of enamel should be

removed

~Equally distributed between mesial & distal surfaces

ENAMEL STRIPPING

~Metal abrasive strips

coarse, medium or fine

~Perforated diamond disks

Reduces both the adjacent teeth

~Safe sided corborundum disks

Less safe & brittle
Difficult to use in posterior region
Thin fissure burs

Should be followed with metal abrasive strips as it can

cause deep scars

~To reduce post-operative sensitivity fluoride application is

advised
Advantages

~Avoid extraction in borderline cases

~Tooth material excess can be reduced achieving better

interdigitation, overjet & overbite

~Broad contacts may add to the stability of results

~Localised mal-alignments can be corrected without

involving many teeth
DISADVANTAGES

~Sensitivity

~Roughened surface increases caries susceptibility

~Difficult to reproduce exact morphology

~Loss of proximal contact may result in food entrapment

ARCH EXPANSION
ARCH EXPANSION

~ Rapid Maxillary expansion devices

~Slow expansion devices

Rapid maxillary Expansion Devices

~Emerson Angell

~Double jackscrew

~Simpler appliance-Walter Coffin

~Dental expansion

~Skeletal expansion in young children

~Korkhaus reintroduced

~Andrew Haas popularised the appliance

PHILOSOPHY

~Dentofacial orthopedic appliance

~Splits the Mid Palatine suture

~Extreme forces on the palatal shelves => opening of the

sutures => true skeletal changes

~Teeth transmit the forces to the maxillary bone proper

ANATOMY MID PALATINE SUTURE & MAXILLA

~Palatal Process of Maxilla & Maxillary process of the

palatine bones

~Floor of the nose and a part of the lateral wall of the nasal
cavity

~Maxillary bones are joined posteriorly & superiorly to

various bones including the frontal,ethmoid, nasal,
lacrimal, zygomatic etc.
~The inter-palatine suture joins the paired palatine bones at
their horizontal plates and is a continuation of the
intermaxillary suture

~It forms the junction of pre-maxilla, the maxilla and the

palatines

~The development of the MPS passes through three distinct

stages

~Individual variation ranging from 15 to 19 years of age

~Greater degree of obliteration occurs posteriorly than

anteriorly with maximum obliteration in the third decade of
life
EFFECTS OF RME

~The posterior teeth are used as handles to transmit

forces to the maxilla

~They tend to tip buccally due to compression of the

PDL on the pressure side

~Bending of alveolar bone

~Limited tipping and extrusion of the teeth

~Midline diastema

~Half the distance of the screw activation

~Diastema closes within six months due to transeptal fiber

traction
MAXILLARY SKELETAL EFFECTS

~Palatine process separate in triangular/

wedge shaped

~Triangular opening in supero-inferior direction,

maximum towards the oral cavity and less towards the
nasal aspect
MANDIBLE

~Rotates downward & backward

~Opening the bite due to buccal tipping(palatal cusps

overhanging)
NASAL CAVITY & ADJACENT CRANIAL BONES

~Increases intranasal space

~Nasal floor broader

~Can correct a deviated nasal septum

~Improvement in nasal breathing

~Parietal, Zygomatic show realignment of sutures in young

indviduals
INDICATIONS

~ Growing individuals with severely constricted maxillary

arches

~Posterior cross bites with real / relative maxillary

deficiency

~Cleft patients

~Along with facemask therapy

~Class III cases with minor maxillary deficiency

~Interceptive orthodontics
TYPES OF RME

~Removable

~Fixed
-Tooth borne
- Tooth & tissue borne
Removable RME Appliances

~Expansion Screw in the midline

~Clasps in the posterior region

~Efficiency is doubtful

~Early mixed dentition

~Patient compliance is doubtful

FIXED RME APLLIANCES

~Isaacson

~Hyrax

~Derichsweiler

~Haas
ACTIVATION

~Orthopedic forces

~Expansion of 0.2 to 0.5 mm a day

~Two one quarter turns in a day- one in the morning

and one in the evening

~1cm expansion achievable in 2 to 3 weeks

RETENTION

~Relapse tendency is high

~Expansion is maintained

~Transpalatal Arch can be given

SLOW EXPANSION DEVICES

~Mild Forces

~50 to 200 gms of force

~2 to 6 months

~Dentoalveolar expansion
INDICATIONS

~Correction of unilateral crossbites

~Correction of narrowed arches

~Preparation of bone grafts in cleft cases

~Minimal crowding in upper arches

~Elimination of displacement
SLOW EXPANSION APPLIANCES

~Screw Appliances

~Coffin Spring

~Quad Helix/ Bi helix

~The Schwartz Plate

DISTALIZATION OF MOLARS

~Posterior movement of maxi./mand.molars

~Increase in arch length

~Before eruption of II molars

Classified as

~ Extra-oral distalizing appliances

~Intra-oral distalizing appliances

EXTRA-ORAL DISTALISING APPLIANCES

~Headgears
Force delivery unit-face bow, J Hook
Force generating unit
Anchor unit-head cap, neck strap

~Unilateral & Bilateral

~Force Magnitude

~Force duration

~Patient Compliance
INTRA-ORAL DISTALISING APPLIANCES

~Screws

~Open-coil springs

~Wire springs incorporated with helices

~Magnets
~Anchorage from palate, rugae region

~Proclinig effect is minimized

~The efficiency is better before eruption of II molars

~Various appliances

Schwartz plate
Sagittal appliance
Open coil springs
Jones Jig
Pendulum appliance
~Lip Bumper appliance

~UPRIGHTING of posterior teeth

~Derotation of Posterior teeth

~Proclination of Anterior Teeth

EXTRACTIONS

~Tooth size Arch Length Discrepancy

Class I crowding / protrusion

Less than 4mm discrepancy-extraction rarely indicated

5-9mm-Extraction/ Non-extraction

10mm & excess Extraction

~Correction of Sagittal Interarch Relationship
Restore Class II Interarch relationship

Class III Interarch relationship

Class I Malocclusion
~Class I Malocclusion
Both arches
I / II Bicuspids
Crowding & proclination

~Class II Malocclusion
Division I
Crowding & proclination
Molar relation

~Class III Malocclusion

Extraction in the lower arch alone
~Extraction for relief of Crowding

~Condition of teeth Fractured, hypoplastic, grossly

decayed tooth,

~Position of crowding
Incisor crowding-I pre-molar extraction
Near the area of the crowding

~Position of the teeth

Grossly malpositioned teeth
Position of the apex of the tooth
Extraction Procedures

~Balancing Extractions

~Compensating extractions

~Phased extractions

~Enforced Extractions

~Wilkinson extractions

~Therapeutic Extractions
BALANCING EXTRACTIONS

~Removal of tooth on the opposite side of the arch in

order to preserve symmetry

Mid-line correction and maintaining the same

COMPENSATING EXTRACTIONS

~Removal of equivalent tooth in opposing arch to

maintain buccal occlusion

~Maintains inter-arch relationship by allowing posterior

teeth to drift mesially
PHASED EXTRACTIONS

~Effect a change in molar occlusion by extracting in one arch

only, a few months earlier than in the other

~Done in premature exfoliation of deciduous teeth

ENFORCED EXTRACTIONS

~Grossly decayed tooth

~Poor periodontal status

~Fractured tooth

~Impacted tooth
WILKINSON EXTRACTION

~Four I Permanent Molars 8-9 yrs of age

~Gross decay

~Enables eruption of third molars

THERAPEUTIC EXTRACTIONS

~Choice of teeth depends on

~Direction & amount of jaw growth

~Discrepancy between size of dental arches & basal arches

~State of soundness, position & eruption of teeth

~Facial Profile

~Degree of dento-alveolar prognathism

~Age of patient

~State of dentition as a whole

~Incisors
Unfavourable impaction

~Buccally/lingually placed tooth

~Gross decay

~Trauma

~Periodontal status
CANINES

~Impaction

~Transposition

FIRST BICUSPIDS

~Close to the center of the arch

~Maintains Molar occlusion

SECOND BICUSPIDS

~Completely excluded from the arch

~Mild anterior crowding

~Maintain soft tissue profile & esthetics

~Open bite cases

I MOLARS

~Minimum space requirement

~Impacted molar

~Open Bite

II MOLARS

~Molar distalising & space creation for pre-molars

~Allow third molar to erupt

III MOLARS

~Late anterior crowding

~Impaction