ORTHODONTICS Part 1: Epidemiology of Malocclusio Crowding !

i cisor cro"di g te ds to i crease i c#ildre as permt teet# erupt $%c permt i cisors re&uire more space t#a primary i cisors !lo"er i cisor cro"di g co ti ues to "orse i to adult#ood !1'( of adolesce ts a d adults #a)e se)ere cro"di g "#ic# re&uires e*tractio of permt teet# to create space Angle Classes Prevalence 1+ Class I ormal occlusio : ,-( of populatio .+ Class I malocclusio : '-( of populatio /most commo + ,+ Class II malocclusio : 1'( of populatio !prese ce of more t#a 'mm o)er0et !class II more commo i "#ites of ort#er Europea desce t 1+ Class III malocclusio : 1( of populatio /least commo + !prese ce of re)erse o)er0et !more pre)ale t i 2sia populatio s !#a)e difficulty ma3i g 4f5 a d 4)5 sou ds Malocclusion !most ofte is hereditary !less fre&ue tly is caused $y t#um$!suc3i g%to gue!t#rusti g6 or trauma Sunday Bite !occurs "#e ppl "% class II profile try to adopt for"ard postural positio of ma di$le to impro)e est#etics Mouth Breathing Characteristics 1+ S3eletal ope $ite /4lo g face sy drome5+ .+ Narro" face ,+ C#ro ic to sillitis 1+ Narro" orop#ary geal space '+ C#ro ic r#i itis 7+ De)iated asal septum Symptoms of Thumb Suc!ing "abit 1+ 2 terior ope $ite !most commo result of t#um$ suc3i g .+ Cross$ite ,+ Co stricted ma*illary arc# !caused $y i creased pressure from $ucci ators muscle duri g suc3i g 1+ Procli ed ma*8 i cisors '+ Retrocli ed ma d8 i cisors 7+ Class II malocclusio !from #a d resti g o c#i "#ic# retards gro"t# of ma di$le Part .: 9ro"t# a d De)elopme t Theories of #rowth Control 1+ Direct ge etic co trol: $o e is directly u der co trol of ge etics .+ Epige etic gro"t# co trol: cartilage is primary determi a t of s3eletal gro"t# a d t#us i directly co trols gro"t# of $o e !cartilage gro"s a d t#e is replaced $y $o e ,+ E )iro me tal gro"t# co trol /:u ctio al matri* t#eory+: gro"t# of $o e is i flue ced $y ad0ace t soft tissues t#roug# e )iro me tal c#a ges i forces e*erted o $o es t#at stimulate t#eir gro"t#

$ndochondral vs %ntramembranous Bone &ormation 1+ E doc#o dral: $o e formed first as cartilage6 t#e tra sformed to $o e !$o es formed t#is "ay are less suscepti$le to e )iro me tal i flue ces duri g gro"t# a d are u der more ge etic co trol !$o es of cra ial $ase /et#moid6 sp#e oid6 temporal+ are e doc#o dral .+ I tramem$ra ous: $o e formed $y secretio of $o e matri* directly "it#i CT6 "%o i termediate formatio of cartilage !$o es formed $y t#is "ay are more i flue ced $y e )iro me tal forces arou d t#em !flat $o es of cra ial )ault6 ma*illa6 a d ma di$le formed i tramem$ra ously #rowth of Cranial 'ault !$o es of cra ial )ault form i tramem$ra ously !at $irt#6 $o es are "idely separated $y loose CT at fo ta elles !appositio of $o e alo g edges of fo ta elles elimi ates ope spaces $ut $o es remai separated $y cra ial sutures !as $rai gro"t# occurs6 cra ial $o es are pus#ed apart a d appositio of e" $o e occurs at sutures !remodeli g also occurs "it# e" $o e added o e*ter al surfaces a d remo)ed o i ter al surfaces #rowth of Cranial Base !cra ial $ase forms $y e doc#o dral met#od !et#moid6 sp#e oid6 a d occipital $o es formed i itially i cartilage a d later tra sformed i to $o e !as ossificatio occurs6 , $a ds of cartilage remai "#ic# are impt gro"t# ce ters called synchondroses 1+ sp#e o!et#moid sy c#o drosis .+ i tersp#e oid sy c#o drosis ,+ sp#e o!occipital sy c#o drosis !eac# sy c#o drosis acts li3e a .!sided epip#yseal plate "% gro"i g cartilage i middle a d $a ds of maturi g cartilage cells e*te di g i $ot# directio s6 "#ic# "ill $e replaced $y $o e !e)e tually6 t#ese sy c#o droses $ecome i acti)e !$o es of cra ial $ase ot affected $y $rai gro"t# #rowth of Ma(illa !ma*illa gro"s i tramem$ra ously !gro"t# occurs at sutures posterior a d superior to ma*illa at its co ectio s to cra ium a d cra ial $ase !ma*illa migrates do" "ard a d for"ard a"ay from cra ial $ase a d u dergoes sig ifica t surface remodeli g !remodeli g i cludes resorptio of $o e a teriorly a d appositio of $o e i feriorly !muc# of a terior mo)eme t of ma*illa is egated $y a terior resorptio 6 "#ile do" "ard migratio is #elped $y i ferior appositio of $o e !additio of e" $o e ca o ly occur at t#e surfaces a d ot i terstitially !t#us6 i creased space for eruptio of posterior teet# occurs $y additio of $o e posteriorly at tu$erosity as ma*illa migrates do" "ard a d for"ard #rowth of Mandible !gro"t# of ma di$le is $ot# e doc#o dral a d i tramem$ra ous !ma0or site of gro"t# is co dylar cartilage !cartilage is tra sformed i to $o e at co dyle as ma di$le gro"s do" "ard a d for"ard6 a"ay from cra ial $ase !most gro"t# of ma di$le occurs $y e" $o e formi g at co dyle a d $y resorptio of a terior part of ramus "% appositio posteriorly

$mbryonic )evelopment of Mandible !ma di$le de)elops i t#e same area as cartilage of 1st p#ary geal arc# /Mec3el;s cartilage+6 $ut de)elopme t of ma d8 itself proceeds lateral to Mec3el;s cartilage a d is e tirely i tramem$ra ous i ature !Mec3el;s cartilage disi tegrates a d its rem a ts are tra sformed i to a portio of i er ear /malleus a d i cus+ !co dylar cartilage de)elops i depe de tly a d is i itially separated $y a gap from $ody of ma di$le !it later fuses "% de)elopi g ma di$ular ramus Mandibular #rowth *otation !as gro"t# of co dyle facilitates mo)eme t of ma d8 do" "ard a d for"ard6 a gap is a)aila$le $t" ma*illa a d ma d8 i "#ic# t#e ma*8 a d ma d8 teet# erupt 1+ 2)erage closi g rotatio : co dylar gro"t# e*ceeds molar eruptio a d ma d8 rotates slig#tly closed o)er time /most commo + !t#is #elps ma3e c#i more promi e t as c#ild ages !allo"s posterior face #eig#t to i crease more t#a a terior face #eig#t .+ Se)ere closi g rotatio : co dylar gro"t# greatly e*ceeds molar eruptio a d ma d8 rotates more su$sta tially closed !leads to de)elopme t of s#orter face a d deep a terior o)er$ite ,+ Ope i g rotatio : co dylar gro"t# is less t#a molar eruptio a d ma d8 rotates ope duri g gro"t# !results i lo ger lo"er face a d te de cy for a terior ope $ite Cephalocaudal #rowth #radient !structures fart#er from t#e $rai gro" more a d later i time !i fetus6 #ead is '-( of $ody< !at $irt# it is ,-(< !at adult6 it is 1.( of $ody !ma d8 is fart#er from $rai t#a ma*illa a d t#us gro"s more a d later i time Scammon+s #rowth Curves 1+ =ymp#oid tissues /to sils6 ade oids+: gro" &uic3ly6 reac#i g .* adult si>e $y age 1-6 t#e i )olute duri g pu$erty to reac# adult si>e .+ Reproducti)e tissues: do ;t gro" muc# u til pu$erty6 a d t#e rapidly i crease to adult si>e correspo di g to pu$ertal gro"t# spurt ,+ 9e eral $ody tissues /muscle6 $o e+: gro" rapidly after $irt#6 t#e slo" some"#at duri g c#ild#ood6 t#e accelerate agai at same time as reproducti)e tissues proliferate /pu$erty+ 1+ Neural tissues /$rai 6 er)ous system+: co ti ue to gro" rapidly after $irt# u til age ? "#e t#ey are already 1--( adult si>e '+ Ma*illa: located closer to $rai so gro"s earlier a d follo"s patter close to eural tissues 7+ Ma di$le: gro"s later t#a ma*illa a d e*#i$its gro"t# t#at parallels ge eral $ody tissues #rowth 'elocity Curve !gro"t# i #eig#t is )ery rapid after $irt# $ut decelerates &uic3ly to a lo"er6 more co sta t le)el i c#ild#ood !arou d pu$erty6 gro"t# accelerated agai 6 reac#i g a pu$ertal gro"t# pea3 $efore slo"i g a d stoppi g at maturity !predicti g timi g of t#is gro"t# spurt may $e impt for ort#o t*t Se( )ifferences !girls reac# gro"t# pea3 arou d . yrs earlier t#a $oys !a)g gro"t# pea3 for girls i 1. yrs6 $oys is 11 yrs !t#ere is co sidera$le i di)idual )ariatio i t#is !ge erally6 earlier t#e gro"t# pea36 t#e s#orter t#e duratio of gro"t# spurt "ill $e a d less o)erall gro"t# t#at "ill occur !girls "ill ge erally start gro"t# soo er6 gro" for s#orter amt of time6 a d gro" less t#a $oys

Predictors of #rowth 1+ C#ro ological age: ot perfect predictor of "#e pea3 gro"t# "ill occur .+ De tal age: e)e less relia$le !c#ildre "#ose teet# erupt early do ;t ecessarily gro" early ,+ S3eletal age: p#ysical gro"t# correlates "ell a+ #a d!"rist radiograp# is sta dard for assessi g s3eletal de)elopme t !ulnar sesamoid and hamate bones used as la dmar3s for timi g adolesce t gro"t# spurt $+ e)aluate )erte$ral $o es from Cep# radiograp# c+ plot i creases i $ody #eig#t o)er time d+ successi)e Cep#s ca $e superimposed to determi e "#e gro"t# spurt #as started%e ded 1+ Se*ual de)elopme t: se*ual de)elopme t a d gro"t# i #eig#t are )ery "ell correlated !se* #ormo es #a)e direct effect o e doc#o dral ossificatio )irections of #rowth in ,aws 1+ @idt#: gro"t# i "idt# of 0a"s is completed $efore adolesce t gro"t# spurt $egi s .+ =e gt#: gro"t# i le gt# of 0a"s co ti ues t#roug# t#e gro"t# spurt ,+ Aertical: )ertical gro"t# co ti ues lo ger t#a gro"t# spurt Cleft -ip and Palate !is most commo cra iofacial defect !is . d o ly to clu$foot i all co ge ital deformities !cleft lip occurs "#e t#ere is failure of fusio $t" medial asal /fro to asal+ process a d ma*illary process !t#is fusio i cludes lip a d al)eolar ridge%primary palate !cleft palate occurs "#e palatal s#el)es fail to fuse !closure of seco dary palate occurs . "ee3s after closure of primary palate !so6 cleft lip occurs $efore cleft palate Part ,: De)elopme t of Occlusio #um Pad Stage !$egi s at $irt# a d goes u til 7 mo t#s /e ds "% eruptio of first i cisor+ !future positio of teet# ca $e o$ser)ed $y ele)atio s a d groo)es o al)eolar ridge Primary )entition Stage !starts "% eruptio of first toot# a d lasts u til a$out 7 yrs old "#e first permt8 toot# erupts !primary ma*8 a terior teet# are a$out ?'( t#e si>e of permt successors !primary ma d8 a terior teet# are a$out 7 mm arro"er mesiodistally t#a t#eir successors !co ditio s: 1+ O)er$ite: )ertical o)erlap of ma d8 teet# $y ma*8 teet# !ca $e measured i mm $ut prefera$ly do e i perce tages /o)er$ite ormally ra ges 1-!1-(+ .+ Ope $ite: lac3 of o)er$ite "#ere t#ere is space $t" ma*8 a d ma d8 teet# ! ot u usual i primary de titio due to #a$its /t#um$suc3i g+ ,+ O)er0et: #ori>o tal dista ce $t" ma*8 a d ma d8 teet# ! ormal )ariatio from -!1mm !#a$its ca cause i creased o)er0et 1+ Spaci g: primary de titio ofte #as ge erali>ed spaci g !especially oted i t"o locatio s called primate spaces a+ $t" lateral i cisor a d ca i e i ma*8 $+ $t" ca i e a d 1st primary molar i ma d8 '+ Cro"di g: u commo to #a)e cro"di g i primary de titio

Primary Molar *elationships 1+ :lus# termi al pla e: distal aspect of . d primary ma*8 a d ma d8 molars are at same le)el !de)elops i to class I /'7(+ or class II /11(+ permt molar relatio s#ip .+ Mesial step: distal of ma d8 . d molar is mesial to distal of ma*8 . d molar !de)elops i to class I most ofte $ut ca $e class III depe di g o se)erity ,+ Distal step: distal of ma d8 . d molar is distal to distal of ma*8 . d molar !de)elops i to class II occlusio !$y age '6 B-( of c#ildre #a)e flus# termi al place or are 1Cmm i mesial step !1st permt molar is guided alo g termi al pla e duri g eruptio 6 so t#e primary molar relatio s#ip "ill determi e permt molar relatio s#ip Mi(ed )entition Stage !starts arou d age 7 "it# eruptio of first permt toot# !as eac# permt toot# erupts6 it is e*pected its a timere /co tralateral toot#+ "ill erupt "it#i 7 mo t#s !4ugly duc3li g stage5: as t"o ma*8 ce tral i cisors erupt6 t#ey mo)e facially a d temporary diastema ofte prese t /prese t i BD( of 7- c#ildre + !"#e permt ca i es erupt6 t#e ce trals mo)e mesial to close diastema !ma d8 i cisors erupt li gual to primary i cisors a d t#e mo)e facially !tra sie t ope $ite may $e prese t o partial eruptio permt a teriors6 $ut resol)es ! ormal c#aracteristics of mi*ed de titio : 1+ molar a d ca i e relatio s#ips are class I .+ lee"ay space prese t ,+ "ell!alig ed or slig#tly cro"ded i cisors 1+ tig#t pro*imal co tacts -eeway Space !differe ce i mesiodistal si>e $t" primary ca i e to primary . d molar a d t#eir permt replaceme ts /permt ca i e to permt . d premolar+ !lee"ay space larger i ma d8 arc# /.8'!1mm per side+ "#ere ma*8 arc# is arou d 18'!.8' mm per side !lee"ay space ca affect e)e tual permt molar relatio s#ip or may aid i resolutio of cro"di g Permanent )entition Stage !$egi s "#e last primary toot# is lost !ma*8 teet# s#ould o)erlap ma d8 teet# )ertically a d $uccoli gually !o)er$ite is ge erally 1-!.-( !o)er0et s#ould $e 1!,mm !arc#es #a)e t"o cur)atures: 1+ Cur)e of Spee: cur)ature i sagittal pla e /:ro t E $ac3+ .+ Cur)e of @ilso : cur)ature i fro tal pla e /=eft E rig#t+ !permt de titio relatio s#ips fairly sta$le o ce esta$lis#ed !e*ceptio i . d!1t# decades of life "#e te de cy for a terior cro"di g to de)elop or "orse

)imensional Changes in )ental Arches 1+ @idt# a+ Ma*8 i terca i e "idt#: i creases $y a$out 7mm $t" ages ,!1, a d 18?mm u til age of 1' $+ Ma*8 i termolar "idt#: i creases .8.mm $t" D!1, a d decreases $y 1mm $y age of 1' !i crease i ma*8 arc# due to al)eolar $o e gro"t# $ei g di)erge t c+ Ma d8 i terca i e "idt#: i creases ,8?mm from ,!1, a d decreases $y 18.mm from 1,!1' d+ Ma d8 i termolar "idt#: i creases 1mm from D!1, a d decreases $y 1mm from 1,!1' .+ =e gt# !arc# le gt# measureme t is at midli e from a poi t mid"ay $t" ce tral i cisors to ta ge t touc#i g distal surfaces of . d primary molars or mesial of 1st permt8 molars a+ Ma*illa: small decrease i arc# le gt# "% age $%c i cisors $ecome more uprig#t $+ Ma di$le: similar decrease i arc# le gt# due to uprig#ti g of i cisors a d loss of lee"ay space ,+ Circumfere ce%Perimeter !measureme t of amt of space a)aila$le for de titio !measured from distal aspect of . d primary molar /mesial of 1st permt molar+ o o e side to distal aspect of . d primary molar /mesial of 1st permt molar+ o ot#er side a+ Ma*illa: i creases )ery slig#tly o)er time $+ Ma di$le: decreases sig ifica tly due to mesial s#ift of permt de titio to fill lee"ay space6 i terpro*imal "ear6 a d li gual positio i g of i cisors Se.uence of $ruption 1+ Primary de titio !$egi calcificatio $t" ,!1 mo t#s i utero !ma d8 teet# start calcificatio $efore ma*8 !eruptio of first primary toot# occurs at a$out 7!? mo t#s a d co ti ue to erupt u til .!, yrs old !typical se&ue ce: CI6 =I6 1M6 C6 .M .+ Permt de titio !permt teet# $egi calcificatio s#ortly after $irt# !1st permt molar: calcificatio $egi s at . mo t#s !,rd molars calcify at D!B yrs old !ma*8 se&ue ce: 1M6 CI6 =I6 1PM6 .PM6 C6 .M6 ,M !ma d se&ue ce: 1M6 CI6 =I6 C6 1PM6 .PM6 .M6 ,M ,+ 9e der: females #a)e eruptio arou d ' mo t#s earlier t#a males $ruption Patterns 1+ I cisors: permt toot# $uds lie lingual and apical to primary i cisors .+ Ca i es: permt ca i e is more facially t#a primary $ut usually right in line ,+ Permt teet# mo)e occlusally and buccally duri g eruptio 1+ Ma*illary arc# is slig#tly lo ger /1.Dmm+ t#a ma di$ular arc# /1.7mm+ $ctopic $ruption !toot# erupts i "ro g place !most li3ely to occur i ma*8 1st molars a d ma d8 i cisors !treated $y placi g $rass "ire $t" primary . d molar a d permt 1st molar !more commo i ma*illa a d assoc8 "% s3eletal class II patter

Part 1: Ort#o Diag osis Angle Classification 1+ Class I ormal occlusio : MF cusp of ma*8 1M fits i $uccal groo)e of ma d8 1M a d i tra!arc# relatio s#ips amo g teet# are correct !ma*8 CI o)erlap ma d8 CI !ma*8 ca i e lies $t" ma d8 ca i e a d 1st PM .+ Class I malocclusio : MF cusp of ma*8 1M fits i $uccal groo)e of ma d8 1M $ut i tra!arc# relatio s#ips amo g teet# are a$ ormal /i correct li e of occlusio + ,+ Class II /distocclusio +: MF cusp of ma*8 1M is a terior to $uccal groo)e of ma d8 1M !ma*8 ca i e mesial to ma d8 ca i e a+ Di)isio 1: ma*illary i cisors flared%protruded /la$io)ersio + $+ Di)isio .: ma*8 i cisors uprig#t%retruded /laterals flared%protruded+ a d deep o)er$ite prese t 1+ Class III /mesiocclusio +: MF cusp of ma*8 1M posterior to $uccal groo)e of ma d8 1M !ma*8 ca i e distal to ma d8 ca i e !pseudo!class III malocclusio : ma d8 i cisors for"ard to ma*8 i cisors "#e i ce tric occlusio 6 $ut pt ca $ri g ma di$le $ac3 w/o strain so ma d8 i cisors touc# ma*8 i cisors Signs of %ncipient Malocclusion 1+ =ac3 of i terde tal spaci g i primary de titio .+ Cro"di g or permt i cisors i mi*ed de titio ,+ Premature loss of primary ca i es Crossbite !teet# are o "ro g side of opposi g de titio !types5 a+ s3eletal: #as smoot# closure to ce tric occlusio $+ fu ctio al: #as de)iatio as pt closes !causes: #ereditary6 0a"!si>e discrepa cy6 oral #a$it /t#um$!suc3i g6 ot to gue!t#rusti g+6 super umerary teet#6 or trauma Posterior Crossbite 1+ Normal: ma*8 li gual cusps fit i to ma d8 ce tral fossa .+ Cross$ite /=i gual cross$ite+: ma*8 $uccal cusps fit i ma d8 ce tral fossa !if $ilateral6 is called a scissor bite ,+ Complete li gual cross$ite: "#ole ma*illary toot# li gual to ma di$ular toot# 1+ Complete $uccal cross$ite: "#ole ma*8 toot# $uccal to ma d8 toot# Crossbite Treatment !cross$ites treated i 0st stage of t(t as tra s)erse dime sio is first to stop gro"i g !posterior cross$ites corrected "% palatal e(pansion /rapid palatal e*pa der+ 1+ e*pa der acti)ated .*%day /-8.'mm per tur + .+ after acti)atio completed6 e*pa der remai s i place for ,!7 mo t#s for $o e to form !after e*pa sio 6 diastema usually forms $t" ce tral i cisors "#ic# closes spo ta eously ! asal floor e*pa sio also occurs 1pen Bite !s#ould $e diag osed early $%c it is ot self!correcti g a d "orse s "% time

&acial Proportions 1+ =ip posture%compete ce: "it# teet# toget#er a d lips at rest6 t#e lips s#ould lig#tly touc# or $e slig#tly apart !a gap of more t#a ,!1mm i dicates lip i compete ce $%c of lo g lo"er face6 protrudi g i cisors6 large o)er0et6 or s#ort lips .+ I cisors at rest /=ip!to!toot#+: amt of upper i cisor s#o"i g $elo" upper lip !.!1mm is co sidered est#etically pleasi g ,+ 9i gi)a at smile: up to 1!.mm of gi gi)a s#o"i g o smili g is est#etically pleasi g6 "% a y more $ei g e*cessi)e Profile $(amination 1+ :acial co )e*ity a+ Co )e*: i dicates class II /retrog at#ic+ $+ Straig#t: i dicates class I /ort#og at#ic+ c+ Co ca)e: i dicates class III /prog at#ic+ or midface deficie cy .+ =ip promi e ce: e)aluated $y *ic!ett+s $sthetic -ine 2$ line3 "#ic# e*te ds from tip of ose to c#i !lips s#ould $e slig#tly $e#i d t#is li e for est#etics !a terior!posterior positio of i cisors affects lip promi e ce a+ :ull: protrusi)e $+ 2)erage c+ :lat: retrusi)e ,+ Nasola$ial a gle: a gle $t" $ase of ose a d upper lip !s#ould $e perpe dicular or slig#tly o$tuse S!eletal *elationships 2Cephalometrics3 1+ Cep#alometric refere ce pla es a+ S!N pla e: a terior cra ial $ase $+ Porio /Po+!Or$itale /Or+: :ra 3fort #ori>o tal pla e !$est #ori>o tal orie tatio to assess lateral s3ull c+ 9o io /9o+!9 at#io /9 +: ma di$ular pla e !steep ma d8 pla e yields lo g a terior facial #eig#t a d a terior ope $ite !flat ma d8 pla e yields s#ort a terior facial #eig#t a d deep $ite .+ Cep#alometric measures a+ SN2: a terior!posterior positio of ma*illa !larger a gle mea s ma*8 is more a terior /prog at#ic ma*8+ $+ SNF: a terior!posterior positio of ma di$le !larger a gle mea s ma d8 is more a terior /prog at#ic ma d8+ c+ 2NF: a terior!posterior differe ce $t" ma*8 a d ma d8 !.!1 degree 2NF i dicated class I s3eletal occlusio !more positi)e a gle i dicates s3eletal class II !more egati)e a gle i dicates s3eletal class III ,+ 4Poor ma ;s cep#5: do e $y facial profile a alysis Moyer+s Mi(ed )entition Analysis !uses si>e of erupted ma d8 permt i cisors to predict si>e of u erupted ca i es a d premolars !ma*8 i cisors ot used $%c t#ey #a)e too muc# )aria$ility i si>e Molar 4prighting !lo g!term loss of ma d8 1st molar causes tippi g6 migratio 6 a d rotatio of ad0ace t teet# i to ede tulous space !t*t do e $y tippi g . d molar distally a d ope i g up space for po tic to replace missi g toot# !s#ould $a d . d molar to pre)e t s#eari g of $rac3ets !timeta$le is 7!1. mo t#s !sta$ili>atio s#ould last u til lami a dura a d PD= reorga i>e

!slo" progress i adult pt most li3ely caused $y occlusal i terfere ces %mpacted Canines !ca $e $roug#t i to arc# t#roug# ort#o tractio after $ei g surgically e*posed !retai ed primary toot# s#ould $e e*tracted !duri g e*posure6 flaps s#ould $e reflected so toot# is pulled t#roug# 3erati i>ed tissue6 ot al)eolar mucosa !ade&uate space i arc# s#ould $e created $efore attempti g to pull impacted ca i e i to positio Part ': Treatme t Pla i g Prioriti5ing the Problem -ist 1+ Systemic disease%pat#ology !must $e co trolled $efore ort#o t*t ca $egi .+ Impacted teet# ,+ Est#etic or occlusal pro$lems a+ I terarc# relatio s#ips ta3e priority o)er i tra!arc# relatio s#ips 1+ Ha$its '+ 9ro"t# pote tial%te de cies Part 7: Fiology of Toot# Mo)eme t &undamental Principles !ort#o mo)eme t results from applicatio of a force system to t#e toot# a d t#e tra sductio of t#at mec#a ical sig al i to a $iological sig al a d respo se !a force system is applied at t#e cro" of a toot# a d t#e mec#a ical sig al is tra smitted to t#e supporti g structures of t#e toot# /$o e6 PD=+ !for mo)eme t to occur6 force must ot ecessarily $e co ti uous6 $ut must $e applied for mi imally accepta$le period of time to elicit $iological respo se eeded !amt of force /#ea)y or lig#t+ determi es t#e $iological pat#"ay of toot# mo)eme t a d formatio or lac3 of formatio of a #yali i>ed >o e "% u dermi i g resorptio !t#e PD=6 a "ell!orga i>ed CT6 remodels sig ifica tly duri g ort#o mo)eme t Pressure vs Tension Sides of Tooth Movement 1+ Pressure%Compressio side: side to"ard "#ic# toot# is mo)i g agai st !"#ere $o e resorptio ta3es place as result of osteoclastic acti)ity !resorptio lacu ae created is called Ho"s#ip lacu ae .+ Te sio side: side opposite t#at "#ic# t#e toot# is mo)i g agai st !appositio of $o e occurs o t#is side !difft8 types of toot# mo)eme t are c#aracteri>ed $y difft8 patter s of stress distri$utio i PD= a d correspo di g areas of $o e resorptio a d appositio a+ I trusio : "#e toot# is i truded6 area of compressio of PD= is co ce trated at ape* of toot# $+ Tippi g: cro" a d ape* mo)e i opposite directio s6 creati g t"o areas of compressio i+ cer)ical area o side to"ard "#ic# toot# is tippi g ii+ apical regio o side opposite "#ic# toot# is tippi g !te sio areas located o opposite sides "#ere compressio occurs !tippi g $est accomplis#ed $y use of finger springs c+ Tra slatio al%$odily mo)eme t: o e side of PD= e*perie ces compressio /side to"ard "#ic# toot# is mo)i g+ a d ot#er side e*perie ces te sio Biological Control of 1rtho Tooth Movement !duri g toot# mo)eme t6 te sio a d compressio occur i PD= a d its t"o i terfaces: 1+ "it# $o e o al)eolar side .+ "it# ceme tum o toot# side !"#e a ort#o force is applied to a toot#6 t"o sce arios ca de)elop depe di g o if force is #ea)y or lig#t

"eavy &orce !use of #ea)y ort#o forces does ot ma3e toot# mo)eme t more efficie t a d actually delays toot# mo)eme t $y causi g a lag period after i itial mo)eme t of toot# "it#i PD= 1+ I itial period of toot# mo)eme t !$o e $e di g a d creatio of pie>oelectric sig al occurs i less t#a 1 seco d !pi>oelectric sig al c#aracteri>ed $y &uic3 decay rate a d productio of e&ui)ale t sig al of opposite directio "#e force is released !PD= t#e compressed a d fluid is e*pressed from area of compressio 6 resulti g from i sta t mo)eme t of toot# "it#i PD= i 1!. seco ds !as fluids e*pressed from PD=6 pai is felt as result of pressure applied "it#i ' seco ds !toot# is o" compressed agai st $o e surface a d o furt#er mo)eme t "ill occur u til resorptio ta3es place !resorptio occurs "it#i al)eolar $o e i marro" spaces a d mo)es to"ard PD= area !appeara ce of osteoclastic cells i marro" spaces is first i dicator of resorptio !resorptio ca last a fe" "ee3s a d o mo)eme t "ill occur u til resorptio is completed "#e #ea)y ort#o forces are applied !compressed PD= u dergoes sig ifica t tissue c#a ges !o compressio side of PD=6 #yali i>ed >o e starts to de)elop /PD= lost all orga i>atio a d ecrosis see + !cells from surrou di g $o e marro" start to migrate i to area from marro" spaces "it#i days a d resorptio simulta eously starts "it#i marro" spaces .+ Seco dary period of toot# mo)eme t /after resorptio + !#yali i>ed PD= is i process of #eali g !seco dary mo)eme t occurs after a lag period duri g "#ic# resorptio ta3es places -ight &orce !use of lig#t force causes a smoot#6 co ti uous toot# mo)eme t "it#out formatio of sig ifica t #yali i>ed >o e i PD= !teet# su$0ected to lig#t forces start to mo)e earlier a d i more p#ysiological "ay !i itial r* i clude partial compressio of $lood )essels a d distortio of PD= !"it#i mi utes6 $lood flo" altered6 o*yge te sio c#a ges6 a d prostagla di s a d cyto3i es released "it#i PD= !meta$olic c#a ges start to appear i t#is area of PD= after a fe" #ours of i itial mo)eme t !PTH6 calcito i 6 fi$ro$last distortio 6 su$sta ce P6 prostagla di s6 a d eurotra smitters !"it#i a fe" #ours6 a sig al tra sductio starts i PD= a d c!2MP le)els i crease !cellular differe tiatio ta3es place i PD= a d coupli g $t" osteoclast%osteo$lasts acti)ities results i fro tal resorptio of $o e Adverse $ffects of 1rtho &orces 1+ Mo$ility !forces cause $o e a d PD= to u dergo remodeli g a d PD= is temporarily "ide ed !moderate mo$ility occurs a d resol)es "it# completio of t#erapy as lo g as t#ere is o acti)e perio d* !if toot# is i traumatic occlusio or pt #as paraf* al #a$its6 mo$ility is sig ifica tly i creased .+ Pai !#ea)y forces cause pai as soo as PD= is i itially compressed !pai typically occurs "it#i fe" #ours if i itiatio of force a d lasts for .!1 days !pai after #ea)y forces is due to de)elopme t of areas of isc#emia or ecrosis /#yali i>atio + i PD= /t#ese areas "ill remodel a d pai "ill decrease+ !$est "ay to mi imi>e pai is to mi imi>e amt of force applied !pts s#ould $e gi)e Tyle ol rat#er t#a aspiri or i$uprofe ,+ Tissue i flammatio !usually results from poor #ygie e6 $ut ca also $e allergic r* to late* or ic3el

1+ Pulpal effects !mild pulpitis or loss of )itality are rare !loss of )itality see i teet# t#at #ad trauma6 restoratio s6 or mo)ed "it# #ea)y forces o)er lo g dista ces !if ape* is mo)ed out of al)eolar $o e6 $lood supply may $e se)ered a d toot# loses )itality '+ Root resorptio !as PD= e*perie ces #yali i>atio 6 t#e ad0ace t ceme tum s#o"s sig s of resorptio as "ell !#ea)y co ti uous forces #a)e more pote tial for root resorptio !resorpti)e defect ca repair depe di g o si>e of defect created !ris3 factors for root resorptio i clude: a+ ge etic factors /family #* of root resorptio + $+ #ea)ier forces c+ si gle rooted teet# d+ trauma6 $ru*ism6 #ea)y masticatio e+ toot# already #ad sig s of resorptio prior to ort#o f+ mo)eme t of roots i to cortical plate !teet# "it# su$sta tial root resorptio $ut i tact margi al periodo tium "ill ot e*perie ce a y more mo$ility t#a u resor$ed teet# Part ?: Mec#a ical Pri ciples i Toot# Mo)eme t &orces !forces are )ectors a d #a)e directio a d mag itude !forces ca act a y"#ere alo g t#eir li e of actio !t#e poi t of force applicatio also i flue ces toot# mo)eme t !a force acti g t#ru t#e ce ter of resista ce of a toot# "ill cause pure tra slatio of toot# i directio of force !pure translation is mo)eme t of all poi ts o toot# i same directio i same amt / o rotatio + !pure tra slatio also called $odily mo)eme t !a force applied t#at is ot at ce ter of resista ce causes rotatio of toot# !for a free $ody floati g i space6 t#e ce ter of resista ce is t#e same as t#e ce ter of mass or gra)ity !for a toot#6 t#e locatio of ce ter of resista ce depe ds o si>e a d s#ape of toot# a d &uality a d le)el of supporti g structures /$o e6 PD=+ !i a #ealt#y toot#6 ce ter of resista ce presumed to $e G t#e dista ce from al)eolar crest to root ape* !t#is is a$out 1-mm from "#ere ort#o $rac3et "ould $e placed o cro" of toot# !ce ter of resista ce is more apical for toot# t#at is perio compromised Moments !mome t is defi ed as a te de cy to rotate a d may refer to rotatio 6 tippi g6 a d tor&ue i ort#o !mome t of force is e&ual to mag itude of force * dista ce of force from ce ter of resista ce /MH:d+ !, orders of toot# mo)eme t: 1+ :irst order: rotatio .+ Seco d order: tippi g ,+ T#ird order: tor&ue !if force is applied at a y poi t ot#er t#a ce ter of resista ce6 a mome t is created !t#e center of rotation is t#e mat#ematical poi t a$out "#ic# t#e toot# appears to #a)e rotated after mo)eme t is complete !i creasi g mag itude of force or applyi g t#e same force fart#er from ce ter of resista ce "ill i crease te de cy for rotatio Couples !a couple is t"o e&ual a d opposite forces !a couple applied to a toot# produces pure rotatio "it#out tra slatio !toot# rotates a$out its ce ter of resista ce regardless of poi t of applicatio of couple

!mag itude of mome t created $y couple depe ds o mag itude of force * dista ce $t" forces /MH:d+ !couples usually applied $y e gagi g a "ire i a edge"ise $rac3et slot Types of Tooth Movement 1+ Pure rotatio !"#e a couple is applied to a toot#6 it rotates arou d its ce ter of resista ce !ce ter of rotatio is at ce ter of resista ce .+ Tippi g !"#e force is applied at $rac3et6 ce ter of resista ce mo)es i directio of force a d cro" tips i directio of force /ape* mo)es i opposite directio + !ce ter of rotatio is apical to ce ter of resista ce !t#is is easiest a d fastest toot# mo)eme t6 $ut least desira$le ,+ Cro" Mo)eme t !force is applied at $rac3et a d small couple is also applied to partially egate tippi g of cro" caused $y t#e force !ce ter of rotatio is at root ape* !is a slig#tly difficult toot# mo)eme t a d occurs slo"ly 1+ Pure Tra slatio !force applied at $rac3et a d larger couple also applied to e*actly egate tippi g of cro" !ce ter of rotatio is so far apical to toot# t#at toot# tra slates "%o tippi g !is difficult a d slo" type of toot# mo)eme t '+ Root Mo)eme t !force applied at $rac3et a d a e)e larger couple is applied to more t#a egate tippi g of cro" so o ly root mo)es i directio of force !ce ter of rotatio is at cro" of toot# !is most difficult a d slo"est toot# mo)eme t Static $.uilibrium !all ort#o applia ces o$ey Ne"to ;s ,rd la" /for e)ery actio t#ere is a e&ual a d opposite r* + !for eac# applia ce6 t#e sum of forces a d sum of mome ts acti g o it e&ual >ero !it is impossi$le to desig a applia ce t#at defies t#is la" of p#ysics Anchorage !defi ed as resista ce to mo)eme t !a c#orage )alue of a y toot# is e&ual to its root surface area 1+ Reciprocal toot# mo)eme t: . e&ual a c#orage )alue teet# are mo)ed agai st eac# ot#er a d mo)e same amt to"ard%a"ay from eac# ot#er .+ Rei forced a c#orage: addi g additio al teet# to a u it to distri$ute force o)er greater area slo"s mo)eme t of a c#or u it !e*8 Headgear or i terarc# elastics ,+ Statio ary a c#orage: teet# mea t to $e t#e a c#or are acti)ated to u dergo difficult6 slo" mo)eme ts "#ic# distri$ute forces o)er large areas of PD= 1+ Cortical a c#orage: a c#or teet# roots are mo)ed i to cortical $o e "#ic# resor$s more slo"ly t#a medullary $o e '+ Impla ts for a c#orage: impla ts6 i cludi g palatal impla ts a d mi iscre"s6 ca ser)e as a$solute a c#orage for #oldi g or mo)i g teet# !a sta$le impla t "ill ot mo)e si ce it #as o PD=

Part D: Ort#o Materials 6ire Material Properties 1+ Stress!strai relatio s#ip a+ stress is t#e i ter al respo se of a "ire to applicatio of e*ter al forces $+ strain is deformatio or deflectio of arc#"ire as co se&ue ce of stress !defi ed as dime sio al c#a ge di)ided $y origi al dime sio .+ Ideal "ire c#aracteristics 1+ #ig# stre gt# .+ lo" stiff ess ,+ #ig# "or3i g ra ge 1+ #ig# forma$ility ,+ @ire properties !dou$li g le gt# of "ire decreases its stre gt# $y #alf6 ma3es it D* less stiff6 a d 1* t#e ra ge !dou$li g diameter of "ire i creases stre gt# $y D*6 i creases stiff ess $y 17*6 a d decreases ra ge $y #alf 1+ @ire Selectio a+ =arge ort#o mo)eme ts: "ires "% lo" load%deflectio rate desira$le $%c produce co sta t lo" forces $+ Small ort#o mo)eme ts: "ires "% #ig# load%deflectio rate desira$le !load%deflectio rate is proportio al to modulus of elasticity of material !stai less steel #as #ig#est modulus of elasticity /#ig#est load%deflectio rate+ ! ic3el!tita ium #as lo"est modulus of elasticity /lo"est load%deflectio rate+< most fle*i$le "ire !load%deflectio rate )aries directly to 1t# po"er of diameter of rou d "ire a d to ,rd po"er of "idt# of recta gular "ire !load%deflectio rate )aries i )ersely to ,rd po"er of le gt# of "ire !i creasi g i ter$rac3et dista ce decreases load%deflectio rate 1rtho Archwire Materials 1+ Nic3el!tita ium: a+ lo" modulus of elasticity $+ e*tremely "ide "or3i g ra ge .+ Feta tita ium /TM2%tita ium!moly$de um alloy+: a+ i termediate modulus of elasticity /#alf of stai less steel a d dou$le Ni!Ti+ $+ e*celle t resilie ce c+ "ide "or3i g ra ge d+ #ig# forma$ility /$e da$le+ e+ #ig# coefficie t of frictio /u desira$le+ ,+ Stai less steel a+ good mec#a ical properties $+ e*celle t corrosio resista ce c+ lo" cost d+ #ig#est elastic modulus /stiffest+ a d lo"est spri g$ac3 !composed of 1D( c#romium /gi)es corrosio resista ce+ a d D( ic3el

Part B: Ort#o 2pplia ces Straightwire 2Pread7usted3 System !origi al desig : orie tatio of $rac3et slot is at rig#t a gles to lo g a*is of toot# a d t#ic3 ess of $rac3et $ase "as same for all types of teet# 1+ 1st order $e d: $e d placed to positio eac# toot# i di)idually i $uccal!li gual directio .+ . d order $e d: $e d placed to pro)ide proper a gulatio i mesiodistal directio ,+ ,rd order $e d: $e d to pro)ide proper a gulatio i $uccal!li gual directio !i e" straig#t"ire applia ce system6 t#is i fo is i corporated i to $rac3ets for eac# i di)idual toot# "#ic# elimi ates eed for 1st6 . d6 ,rd order $e ds !t#ese $uilt!i attac#me ts #elp ac#ie)e proper positio of a i di)idual toot# !$uilt!i ad0ustme t of eac# $rac3et system is called t#e brac!et prescription !pre!ad0usted applia ces allo" t#e follo"i g: 1+ Rotatio al co trol .+ Hori>o tal co trol ,+ Mesiodistal tip co trol! Frac3et slot is a gulated relati)e to t#e $ase of t#e $rac3et to pro)ide t#e proper tippi g mo)eme t of eac# toot# 1+ Tor&ue! Frac3et slot is a gulated la$ioli gually to pro)ide t#e proper root a d cro" mo)t Brac!ets 1+ Metal $rac3ets: made of stai less steel !disad)a tage is poor est#etics .+ Ceramic $rac3ets: made of mo ocrystalli e%polycrystalli e ceramics !#ig#ly est#etics6 $ut pro e to fracture !also #a)e #ig# frictio al resista ce to slidi g mec#a ics so ca cause a$rasio of opposi g teet# ,+ Self!ligati g $rac3ets: special loc3i g mec#a ism i corporated i to $rac3et system to e gage arc#"ire to elimi ate eed for ligatures !s#orte t*t time $y reduci g frictio $%c "ire is 3ept e gaged i $rac3et slot Bands !all of teet#6 i cludi g molars6 ca $e $o ded $ut it is still preferred to $a d t#e molars !prior to $a di g6 separators are placed $t" teet# to create space for $a d fitti g a d ceme tatio !types of separators: 1+ elastomeric .+ metal !glass io omer ceme t used $%c fluoride!releasi g properties Bonding !$rac3ets attac#ed to e amel usi g $o di g resi s 1+ Direct $o di g: direct attac#me t of ort#o applia ces to teet# usi g c#emical or lig#t!cured ad#esi)es .+ I direct $o di g: $rac3ets first positio ed o study casts a d t#e tra sferred to mout# usi g custom tray !more tec# i&ue!se siti)e $ut less c#airside time eeded a d more precise !pri ciples mec#a ism of attac#me t $t" toot# a d resi is mec#a ical i terloc3i g of $o di g age t a d etc#ed e amel !$o di g procedure: 1+ e amel prop#yla*is to remo)e pellicle a d e #a ce "etta$ility of e amel for acid etc#i g .+ e amel etc#i g "% ,?( p#osp#oric acid ,+ $rac3et positio i g a d secured "% resi ad#esi)e a d lig#t!cured 6hen to 4se Bands 1ver Brac!ets 1+ Need to resist $rea3age /#ea)y masticatio of cuspal i terfere ce .+ Teet# t#at eed li gual a d la$ial attac#me t ,+ Teet# "% s#ort cli ical cro" s 1+ Toot# surfaces i compati$le "% $o di g /ameloge esis imperfect6 stai less steel cro" +

Ma7or Components of *emovable Appliances 1+ Rete ti)e compo e t: 2dams clasps6 $all clasps6 etc8 .+ :rame"or3%$aseplate: made of acrylic a d pro)ides a c#orage ,+ 2cti)e%toot#!mo)i g compo e t: spri gs6 0ac3scre"s6 elastics 1+ 2 c#orage compo e t: resists force of acti)e compo e t /acrylic $aseplate6 la$ial $o"+ Advantages/)isadvantages of *emovable Appliances 1+ 2d)a tages a+ impro)ed #ygie e $+ i creased pt comfort c+ la$ fa$ricatio decreases c#air time .+ Disad)a tages a+ depe de t of pt complia ce $+ ca ;t ac#ie)e t"o!poi t toot# co tact6 so $odily mo)eme t impossi$le c+ ca o ly ac#ie)e toot# tippi g Components of &i(ed Appliances 1+ Fa ds .+ Frac3ets ,+ 2rc# "ires 1+ 2u*iliaries /elastics%ligatures+ Appliances to Modify #rowth of Ma(illa and Mandible !t#ese applia ces allo" differe tial gro"t# of 0a"s !i adolesce ce6 ma di$le #as more pote tial for gro"t# t#a ma*illa !gro"t# modificatio is most successful i pre!adolesce t c#ildre "% good complia ce a d gro"t# pote tial !applia ces: 1+ Headgear .+ :* al applia ces /Her$st6 acti)ator6 $io ator6 t"i $loc3+ "eadgear !uses: 1+ modify gro"t# of ma*illa /restrai gro"t# to allo" ma d8 to catc# up+ .+ retract /distali>e+ or protract ma*illary teet# ,+ rei force a c#orage !usually used i s3eletal class II gro"i g pts !#eadgear s#ould $e "or at least D #rs per day /prefera$le 11 #rs+ !for ort#opedic%s3eletal c#a ges6 force of .'-!'-- g%side recomme ded !for de tal c#a ges6 force of 1--!.-- g%side recomme ded "igh Pull "eadgear !used i pts "% class II malocclusio 6 i creased ADO6 mi imal o)er$ite6 a d gummy smiles !co sists of #ig#!pull #eadstrap a d face$o" "#ic# i serts i to #eadgear tu$es of ma*81st molar attac#me ts !o$0ecti)es of applia ce: restrict do" "ard a d a terior ma*8 gro"t# !places distal and intrusive 2upward3 force o ma*illa Cervical Pull "eadgear !used to correct class II malocclusio "% deep $ite !co sists of cer)ical ec3strap a d face$o" "#ic# i serts i to tu$es of ma* 1st molar attac#me ts !o$0ecti)es: 1+ restrict a terior gro"t# of ma*illa .+ distali>e a d erupt ma*illary molars !places distal and e(trusive 2downward3 force o ma*illa

, "oo! "eadgear 2Straight Pull3 !co sists of #ig#!pull #eadstrap t#at attac#es to t"o #oo3s o a terior part of ma*8 arc#"ire !ca $e used to deli)er posteriorly directed 2straight distal direction3 forces to ma*illa !used most ofte to retract ca i es a d i cisors Protraction "eadgear 2*everse Pull3 !used i pts "% class III malocclusio "#ere t#ere is ma*8 deficie cy !protracts ma(illa !co sists of . pads t#at rest of soft tissue i fore#ead a d c#i regio "#ic# are co ected $y midli e frame"or3 !a terior "ire "% #oo3s also co ected to frame"or3 to accommodate do" "ard a d for"ard pull o ma*illa )ia elastics !o ly #eadgear "% a e*traoral compo e t Chin Cup/Cap !ca $e used to correct class III malocclusio s from e*cessi)e ma di$ular gro"t# !"or3s $y restrai i g ma di$ular co dylar gro"t# !co sists of #eadstrap a d cup t#at fits o c#i !desig ed to deli)er forces i superior a d posterior directio to co dyles )ia c#i &unctional Appliances !#old ma di$le i protrusi)e positio a d tra smit forces created $y stretc# of muscles a d soft tissues to de tal a d s3eletal compo e ts to produce mo)eme t of teet# a d modificatio of gro"t# !desig ed to modify gro"t# duri g mi*ed de titio !#a)e de tal 2ND S3eletal effect !used to correct class II malocclusio $y restrai i g ma*illa a d displaci g ma di$le "#ile still allo"i g ormal ma di$ular gro"t# !applia ces: 28 Toot#!$or e 1+ Her$st ,+ Fio ator .+ 2cti)ator 1+ T"i $loc3 F8 Tissue!$or e 1+ :ra 3el applia ce /o ly tissue!$or e applia ce+ !alters ma d8 posture a d co tour of facial tissue !remo)a$le applia ce "erbst Appliance !co sists of pisto a d tu$e de)ice t#at places ma di$le i for"ard positio as pt closes mout# !#olds ma di$le for"ard to i duce gro"t# !usually ceme ted or $o ded to ma*8 a d ma d8 de tal arc#es !ma*8 a d ma d8 frame"or3s spli ted toget#er )ia pi a d tu$e de)ice !s#o"s i creased te de cy for ma d8 i cisors to flare due to forces i directly deli)ered to t#ese teet# !ca $e fi*ed /most ofte + or remo)a$le Activator !co sists of acrylic $ody t#at co)erts part of palate a d li gual aspect of ma d8 ridge a d la$ial $o" t#at fits a terior to ma*8 i cisors !o acrylic ad0ace t to ma*8 posterior teet#6 facets are cut to allo" occlusal6 distal6 a d $uccal mo)eme t of teet# !o li gual aspect of ma d8 posterior teet#6 facets allo"s occlusal a d mesial mo)eme t !o$0ecti)es: 1+ acti)ates ma di$ular gro"t# to correct class II malocclusio .+ tip a terior teet# ,+ co trol eruptio of teet# )ertically !is first remo)a$le f* al applia ce

Bionator !ad)a ces ma d8 to edge!to!edge positio to stimulate ma d8 gro"t# for correcti g class II malocclusio !similar desig to acti)ator $ut less $ul3y a d less impede t to speec# !co sists of li gual #orses#oe!s#aped acrylic "% "ire i palatal area !facets placed i acrylic to guide posterior teet# a d #old ma di$le i for"ard positio !la$ial $o" prese ts a terior to ma*illary i cisors to elimi ate pressure from $uccal musculature !is a remo)a$le applia ce Twin Bloc! Appliance !#as t"o!part desig "% i teractio $t" ma*8 a d ma d8 parts to co trol #o" muc# ma d8 is postured for"ard a d #o" muc# ma*8 a d ma d8 are separated )ertically !due to t"o!part desig 6 it is easier to tolerate $y pts !ca $e remo)a$le or ceme ted !postures ma d8 for"ard Pendulum Appliance !used to correct class II malocclusio $y distali>i g ma*8 molar teet# !ca also f* to e*pa d ma*illa $y i corporati g e*pa sio scre" i to applia ce !if e*pa di g scre" used6 it is called a Pende( appliance Appliances to Correct Crossbites !correct tra s)erse discrepa cies $y e*pa di g palate at midpalatal suture or $y de tal e*pa sio 1+ Rapid palatal e*pa sio : occurs at rate of -8'mm%day .+ Slo" palatal e*pa sio : occurs at rate of 1mm%"ee3 !de)ices: 1+ Hyra* applia ce 1+ Iuad!#eli* @!arc# .+ Haas applia ce '+ Tra spalatal arc# ,+ Ha"ley "% 0ac3scre" "yra( Appliance !most commo type of rapid palatal e*pa der for s3eletal e*pa sio !scre" acti)ated $y at least -8.'mm%day for rapid e*pa sio !ma*8 arc# "idt# i creased $y ope i g midpalatal suture !e*pa sio co ti ued u til li gual cusps of ma*8 posteriors co tact li gual i cli es of $uccal cusps of ma d8 posteriors !usually results i diastema formatio $t" ma*8 ce tral i cisors6 "#ic# closes o its o" from pull of supracrestal fi$ers !rete tio eeded for ,!7 mo t#s after acti)e e*pa sio completed "% de)ice remai i g i place "aas Appliance !causes s3eletal e*pa sio of palate $y use of acrylic pads placed i co tact "% palatal mucosa "#ic# allo"s forces from applia ce to apply to u derlyi g #ard tissues to mi imi>e de tal tippi g !disad)a tages are i flammatio of palate a d difficult #ygie e "awley Appliance w/ ,ac!screw !ca $e used for de tal or s3eletal e*pa sio !used to correct mild cross$ites 8uad "eli(/6 Arch !mostly used for de tal e*pa sio !s#ould $e used "#e o ly small amt of e*pa sio

eeded

Transpalatal Arch !used for de tal e*pa sio !e*te ds from o e ma*8 1st molar to co tralateral 1st molar alo g co tour of palate .!,mm a"ay from tissue

!ca $e used for e*pa sio or restrictio of palatal gro"t# Appliances 4sed in Mi(ed )entition 1+ Na ce applia ce: used as space mai tai er !#as "ire soldered to palatal aspect of ma*8 1st molars a d #as acrylic $utto t#at rests o palate .+ =o"er li gual arc#: ca $e used for space mai te a ce6 a c#orage6 or e*pa sio !#as "ire adapted to li gual surfaces of ma d8 i cisors ,+ =ip Fumper: used to co trol or i crease ma d8 de tal arc# le gt#6 uprig#t molars6 a d pre)e t lo"er lip from getti g $t" ma*8 a d ma d8 i cisors !remo)es pressure of $uccal musculature o teet# to allo" lateral a d a terior de toal)eolar de)elopme t !pro$lem is it does cause some distal tippi g of ma d8 1st molars Appliances 4sed to Control 'ertical )imension 1+ I trusio arc#: arc#"ire used for deep$ite correctio !causes e*trusio at molars a d i trusio at i cisors .+ E*trusio arc#: arc#"ire used for ope $ite correctio !causes i trusio at molars a d e*trusio of i cisors $lastics !elastomeric $a ds used to produce forces for toot# mo)eme ts 1+ Class I elastics /i trama*illary+: used for tractio $t" teet# i same arc# .+ Class II elastics /i terma*illary+: "or from toot# i a terior ma*illa /ca i e+ to toot# i posterior ma di$le /1st molar+ !used to correct class II malocclusio 6 reduce o)er$ite6 a d restrict ma*8 a teriors ,+ Class III elastics /i terma*illary+: "or from toot# i posterior ma*illa /1st molar+ to toot# i a terior ma di$le /ca i e+ !used to protract ma*8 posterior teet# or impro)e o)er0et i edge!to!edge $ites or a terior cross$ite 1+ Cross$ite elastics: "or from palatal portio of ma*8 teet# to $uccal portio of ma d8 teet# !corrects cross$ite !also causes e*trusio of teet# so use cautio i pts "% ope $ite te de cy '+ 2 terior diago al elastics: ru from o e side of ma*8 teet# to ot#er side of ma d8 teet# crossi g midli e !used to correct u alig ed midli es

Part 1-: Early Treatme t $arly Treatment !desig ed to alle)iate or pre)e t moderate!se)ere ort#o pro$lems $efore permt de titio #as fully erupted !ofte furt#er compre#e si)e t*t "ill $e eeded o ce full permt de titio #as erupted Crowded and %rregular Teeth !caused $y lac3 of ade&uate space for alig me t or i terfere ces "% ormal eruptio 1+ Space mai te a ce: used i cases "#ere primary teet# #a)e $ee lost a d space is ade&uate !$a d a d loop6 distal s#oe /$efore eruptio of permt molar+6 li gual arc#6 Na ce applia ce /ma*8+ .+ Space regai i g: used for locali>ed space loss less t#a ,mm !remo)a$le applia ce "% fi ger spri gs to tip teet# distally6 #eadgear6 li gual arc#6 lip $umper6 or limited fi*ed applia ce ,+ Moderate cro"di g: less t#a 1mm a+ arc# e*pa sio /co tro)ersial+ $+ e*tractio of primary ca i es /must $e follo"ed $y li gual #oldi g arc#+ c+ flari g of i cisors /$y fi*ed or remo)a$le applia ces+ d+ strippi g i terpro*imal e amel from a terior teet# 1+ Se)ere cro"di g: more t#a 1mm a+ 2rc# e*pa sio /co tro)ersial+ $+ Serial e*tractio : timed e*tractio of primary a d permt teet#< used for cro"di g o)er 1-mm i+ e*tract primary i cisors ii+ e*tract primary ca i es to allo" permt i cisors to erupt iii+ e*tract primary 1st molars to allo" permt 1st premolar to erupt i)+ e*tractio of permt 1st premolars to allo" permt ca i e to erupt a d alig !serial e*tractio used primarily for se)ere class I malocclusio !co trai dicated i deep $ites !i creased o)er$ite usually results as i cisors tip li gually i to e*cess space !compre#e si)e t*t almost al"ays eeded after serial e*tractio to get teet# i to ideal alig me t Anterior Spacing 1+ Ma*8 midli e diastema /less t#a .mm+ !usually is self!correcti g $ut t*t i dicated if est#etics are co cer or if ce tral i cisors are i #i$iti g eruptio of lateral i cisors a d ca i es !large space may i dicate super umerary toot# /mesiode s+ or missi g lateral i cisors .+ =arge ma*8 midli e diastema /o)er .mm+ ! ot li3ely to close o its o" !fi*ed ort#o applia ces may $e eeded !fre ectomy after t*t may $e i dicated if space re!ope s or tissue $u c#es after t*t ,+ 9e erali>ed a terior spaci g !postpo e t*t u til t#ere is a est#etic complai t !if spaci g is accompa ied $y protrusio 6 a fi*ed ort#o applia ce usually re&uired $ruption Problems 1+ O)er!retai ed primary teet#: remo)e primary toot# to e courage eruptio of permt toot# .+ 2 3ylosed primary teet#: usually resor$ o t#eir o" $ut ca $e remo)ed if causi g delay i permt toot# eruptio !if permt successor is missi g6 a 3ylosed primary toot# s#ould $e remo)ed to pre)e t )ertical al)eolar defect ,+ Ectopic eruptio : eruptio of toot# i to u e*pected locatio or i to ad0ace t toot# locatio a+ =ateral i cisors: may cause loss of ad0ace t primary ca i e or midli e s#ift !usually i dicates lac3 of sufficie t space !treat $y e*tracti g primary ca i es or space regai i g $+ Ma*8 1st molars: may erupt i to primary . d molar !treat $y uprig#ti g t#e erupti g 1st molar

c+ Ma*8 ca i es: may lead to ca i e impactio or resorptio of ad0ace t lateral i cisor !e*tractio of primary ca i e i dicated Missing Teeth 1+ Ma di$ular . d premolars a+ mai tai i g primary . d molars may $e optio $+ some reductio i "idt# of primary . d molar may $e eeded to attai good posterior i terdigitatio c+ early e*tractio of primary . d molars /age ?!B+ ca $e do e to e courage closure of space .+ Ma*illary lateral i cisors a+ su$stitute ca i e i lateral i cisor positio is optio $+ retai i g space for later replaceme t is optio c+ $est c#oice may depe d o occlusio a d est#etic dema ds 1cclusal *elationship Problems 1+ Posterior cross$ite: usually due to ma di$ular s#ift a+ e&uili$ratio to elimi ate s#ift $+ ma*illary e*pa sio "% applia ce s#ould follo" .+ 2 terior cross$ite: must differe tiate s3eletal from de tal causes a+ s3eletal: due to deficie t ma*illary or e*cessi)e ma di$ular gro"t# $+ De tal: due to i ade&uate space !after creati g space6 teet# ca $e mo)ed for"ard "% ort#o applia ce "% or "%o e*tracti g ad0ace t primary teet# ,+ Ma*illary de tal protrusio "% spaci g !may $e due to s3eletal discrepa cy or t#um$suc3i g !t*t i dicated if est#etics are co cer or if da ger of trauma !treat "% remo)a$le applia ce to uprig#t teet# 1+ Deep $ite !$iteplates ca $e used to ope $ite posteriorly a d allo" eruptio of posterior teet# !i trusio ca also $e used '+ Oral #a$its a d ope $ites !pacifiers a d t#um$suc3i g ca cause i creased o)er0et6 decreased o)er$ite6 a d POSTERIOR cross$ite !as lo g as #a$it stops $efore eruptio of permt i cisors6 most of egati)e c#a ges resol)e o t#eir o" !to stop #a$its6 ca use remi ders /$a dage o fi ger6 #a$it applia ce+6 re"ard system6 etc8 !to gue cri$6 $luegrass applia ce ca $e used !if applia ce must $e used it s#ould remai i place for 7 mo t#s after #a$it appears to #a)e stopped !ope $ites t#at persist after #a$it ceases are li3ely due to s3eletal cause a d may eed more t*t !ort#o a d surgical t*t Part 11: 9ro"t# Modificatio s Timing of #rowth Modification !successful gro"t# modificatio ca occur o ly duri g periods of gro"t# !early modificatio ofte re&uires ret*t $%c u fa)ora$le gro"t# co ti ues !"aiti g u til permt de titio erupts may $e too late for modifyi g gro"t#6 especially i girls Treatment of Mandibular )eficiency 2Class %%3 !timi g s#ould $e "#e ma di$le is acti)ely gro"i g /$efore pea3 adolesce t gro"t#+ 1+ Headgear: restrai s ma*8 gro"t# for"ard to allo" ma di$le to gro" ormally to catc# up !puts posterior forces o ma*8 1st molars .+ :u ctio al applia ces: stimulate ma di$ular gro"t# $ut lo g!term i crease i si>e ot see !also puts a restrai i g force o ma*8 gro"t# !mo)e ma d8 teet# a teriorly a d ma*8 teet# posteriorly

Treatment of 'ertical )eficiency 2Short &ace3 1+ Cer)ical #eadgear: #as e*trusi)e force o ma*8 molar a d it "ill erupt .+ :u ctio al applia ces: allo" eruptio of upper a d lo"er posterior teet# Treatment of 'ertical $(cess 2-ong &ace3 1+ Hig#!pull #eadgear: "ill i #i$it eruptio of ma*8 posterior teet# .+ :u ctio al applia ce "% $ite $loc3s: $loc3s posterior eruptio Treatment of Ma(illary )eficiency 1+ E*pa sio : treats tra s)erse deficie cy .+ Protractio or re)erse!pull #eadgear: ca correct a terior!posterior deficie cy /class III+ !a terior force placed o ma*illa to e courage gro"t# at ma*illary sutures !ideal timi g is early /D!B yrs+ to e courage ma*illary gro"t# si ce ma*8 gro"s earlier t#a ma di$le Treatment of Mandibular $(cess 1+ C#i cup t#erapy: restrai s ma di$ular gro"t# !ge erally re!directs ma d8 gro"t# do" "ard t#a actually stoppi g it !co trai dicated i lo g!faced pts Treatment of &acial Asymmetry !asymmetry may $e due to co ge ital a omaly or early co dylar fracture 1+ 2symmetrical f* al applia ces may $e useful .+ Early surgery may $e i dicated "#e asymmetry is progressi)ely "orse i g Part 1.: Compre#e si)e Treatme t Comprehensive Treatment !i )ol)es complete fi*ed applia ces o ce all permt teet# #a)e erupted $(traction vs 9one(traction )ecisions ! eed for e*tractio s /usually 1st premolars+ is dictated $y amt of cro"di g prese t !"#e space is eeded6 arc#es ca $e e*pa ded a d a terior teet# flared $ut o ly to limited degree !e*pa di g too muc# ca lea)e teet# u sta$le due to lac3 of $o e support !ot#er optio is to create space $y e*tracti g teet# !a ot#er i dicatio for e*tractio is to camouflage a class II or III malocclusio $y e*tracti g premolars i o e arc# o ly to ac#ie)e class I ca i es a d #a)e ormal o)er0et a d o)er$ite a+ upper premolars "ould $e e*tracted to camouflage a class II $+ lo"er premolars "ould $e e*tracted to camouflage a class III !t#ere may $e est#etic co sideratio s to remo)e or ot remo)e teet# si ce a terior toot# positio affects lip full ess !remo)i g premolars a d uprig#ti g i cisors i creases o)er$ite6 "#ereas alig i g moderately cro"ded teet# "%o e*tractio s flares i cisors a d decreases o)er$ite %ndications for $(tractions 1+ =arge amou t of cro"di g .+ Mi imal o)er$ite or prese ce of ope $ite ,+ :lared i cisors 1+ :ull%protrusi)e lips '+ 2cute asola$ial a gle 7+ 2 terior recessio or mi imal attac#ed gi gi)al ?+ To camouflage class II or class III relatio s#ip D+ Missi g or se)erely compromised teet# B+ 2symmetrical occlusio /u ilateral class II or class III+

%ndications to Avoid $(traction 1+ Mi imal cro"di g or spaci g .+ Deep o)er$ite ,+ Jprig#t i cisors 1+ :lat%recessi)e lips '+ O$tuse asola$ial a gle Stages of Comprehensive Treatment 1+ 2lig me t: use lig#t6 fle*i$le "ires i itially6 follo"ed $y slig#tly stiffer "ires .+ O)er$ite correctio : must $e do e $efore molar correctio a d space closure si ce deep o)er$ite "ill pre)e t posterior mo)eme t of i cisors to ormal o)er0et a+ e*trusio of posterior teet# ca #elp pts "% s#ort lo"er face /co trai dicated i pts "% lo g face+ $+ i trusio of a terior teet# /ma*8 or ma d8+ ca $e do e $ased o est#etics c+ flari g of a terior teet# ca decrease o)er$ite ,+ Correctio of molar relatio s#ip a+ gro"t# modificatio $+ i terarc# elastics c+ distal mo)eme t of ma*8 molars 1+ Space closure a+ i terarc# elastics d+ #eadgear '+ Root correctio : if spaces #a)e $ee closed6 teet# may #a)e tipped i to e*tractio space a d roots "ill eed to $e paralleled to impro)e sta$ility a d perio #ealt# !i cisors may #a)e uprig#ted duri g retractio a d roots may eed to $e tor&ue li gually 7+ Detaili g%:i is#i g a+ I tra!arc#: fi al toot# positio i g $y re!$rac3eti g mis$rac3eted teet# or $y small $e ds i "ire to elimi ate small discrepa cies $+ I ter!arc#: settli g of occlusio i to solid relatio s#ip )ia lig#t "ires or )ertical elastics !ca also use a positioner /plastic applia ce made "% teet# reset i to ideal positio + ?+ Special co sideratio s a+ Toot# si>e discrepa cies: smaller%larger teet# i o e arc# may affect i tercuspatio !large teet# may re&uire i terpro*imal reductio /IPR+ to reduce "idt# !small teet# may re&uire $uild!ups to fill space !)ery small spaces ca $e mas3ed $y tippi g teet# to ta3e up more space $+ J fa)ora$le gro"t#: pts "% a ticipated u fa)ora$le gro"t# patter s may use co ti ued #eadgear at ig#t c+ O)ertreatme t: a ticipated re$ou d of a terior!posterior discrepa cies6 cross$ites6 or rotatio s may $e o)ercorrected i t*t i a ticipatio t#at t#ey "ill re$ou d after"ards to some degree d+ Supracrestal fi$erotomy: supracrestal gi gi)al fi$ers e*ert some elastic force t#at may mo)e teet# after t*t !cutti g t#ese fi$ers #as $ee s#o" to sig ifica tly reduce6 $ut ot elimi ate6 t#is te de cy

Part 1,: Rete tio Purposes of *etention 1+ 2llo" time for reorga i>atio of gi gi)al a d PD= fi$ers !reorga i>atio of PD= occurs i ,!1 mo t#s a d full!time rete tio is recomme ded for t#at time !part!time rete tio after 1 mo t#s to arou d 1. mo t#s is recomme ded to allo" more complete reorga i>atio of PD= .+ Pre)e t soft tissue pressures from alteri g post!t*t toot# positio ,+ Hold e" positio of teet# u til gro"t# is completed a+ Rete tio after class II correctio : relapse may occur $+ Rete tio after class III correctio : relapse may occur due to co ti ued ma d8 gro"t# c+ Rete tio after o)er$ite correctio : retai er "% acrylic li gual to ma*8 i cisors usually $loc3s deepe i g of $ite d+ Rete tio after ope $ite correctio : co ti uatio of t#um$suc3i g or to gue t#rusti g may i trude i cisors e+ Rete tio after ma d8 i cisor alig me t: pressure from lip may cause cro"di g of ma d8 i cisors !late ma d8 gro"t# is also possi$le co tri$utor to ma d8 a terior cro"di g ! o e)ide ce t#at ,rd molar eruptio causes i cisor cro"di g f+ Perma e t rete tio : may $e eeded if teet# #a)e $ee placed i i #ere tly u sta$le positio s *emovable *etainers 1+ Ha"ley retai er !i corporates clasps for rete tio a d a outer $o" "% ad0ustme t loops !acrylic o palate ca act as pote tial $iteplate to co trol o)er$ite !outer $o" retai s i cisor positio a d rotatio s !clasps or "ires t#at cross t#e occlusio may "edge space ope or pre)e t closure of spaces t#at remai /disad)a tage+ .+ @rap!arou d retai er !similar to Ha"ley retai er $ut "%o "ires t#at cross t#e occlusio ,+ Positio er !may $e used as fi is#i g de)ice a d t#e as retai er !are $ul3y a d t#erefore ot "ell tolerated ! ot "or full!time a d t#erefore may ot retai rotatio s "ell !mai tai s i tra!arc# a d i ter!arc# relatio s#ips 1+ Esse* applia ce: )acuum formed !rapid6 eco omical6 a d est#etic &i(ed *etainers !$o ded fle*i$le li gual "ires attac#ed to i di)idual teet# or $o ded rigid "ires $o ded to . teet# /especially $t" lo"er ca i es+ !mai tai ma d8 i cisor positio 6 #old diastemas closed6 mai tai space for po tic%impla t6 a d 3eep e*tractio spaces closed Active *etainers !used for realig me t of irregular teet# !irregular teet# are reset o a model a d retai er is made to e" toot# setup !retai er eeds to #a)e some fle*i$ility to fit o)er irregular teet# !i terpro*imal reductio may $e re&uired to allo" space for teet# to rotate Post 1rthodontic Circumferential Supracrestal &ibrotomy !i dicated for rotated ma*8 lateral i cisors !supraal)eolar tissue respo si$le for relapse of ort#o!rotated teet# !i cisio i sulcus made to crest of $o e "#ere collage fi$ers i sert i to toot# root

!elimi ates collage fi$er retractio a d allo"s e" fi$ers to form "#ic# "ill #elp retai toot# i e" positio Part 11: 2dult Treatme t%I terdiscipli ary Treatme t Periodontal Aspects of Adult Treatment !a y perio co ditio s s#ould $e sta$ili>ed prior to ort#o t*t !good oral #ygie e must $e mai tai ed $%c gi gi)itis i adults may progress to perio d* /t#is is rare i 3ids+ !le)el a d co ditio of attac#ed gi gi)al must $e mo itored to pre)e t recessio !pts "% #* of perio disease must $e mo itored o fre&ue t sc#edule /e)ery .!1 mo t#s+ !steel ligatures retai less pla&ue t#a elastic ligatures !lo"er forces ca $e used o teet# "% reduced $o e support $%c less PD= area Proper Se.uence for %nterdisciplinary Treatment 1+ Disease co trol p#ase /caries6 perio d*+ .+ Ort#o toot# mo)eme t ,+ Defi iti)e t*t /perio $o e co touri g6 cro" s6 impla ts6 etc+ -ac! of #rowth in Adulthood !adults do ;t #a)e $e efit of ma di$le gro"t# duri g t*t so all i terarc# correctio s must $e made de tally or "% surgery !"%o aid of gro"t# to suppleme t de tal c#a ges6 t*t progresses more slo"ly e)e t#oug# toot# mo)eme t itself may progress at same rate Part 1': Com$i ed Surgical a d Ort#o Treatme t %ndications for Combined Surgical 1rtho T(t !surgery i dicated "#e pro$lem too se)ere for ort#o alo e !adults do ;t #a)e gro"t# modificatio optio s a)aila$le a d may eed surgical i ter)e tio s !f* al limitatio s a d est#etic goals may $e i dicatio s for surgery e)e if ort#o correctio s alo e are possi$le Anterior Posterior Surgical Corrections 1+ Ma*illary surgery a+ 2d)a ceme t /to correct class III+: =e:orte I do" fracture of ma*illa mo$ili>es it so it ca $e ad)a ced $+ Set$ac3 /to correct class II+: it is difficult to mo)e e tire ma*illa posteriorly6 so usually a premolar is e*tracted a d a terior segme t is mo)ed posteriorly /segme tal osteotomy+ .+ Ma di$ular surgery a+ 2d)a ceme t /to correct class II+: $ilateral sagittal split osteotomy of ramus is preferred met#od $+ Set$ac3 /to correct class III+: $ilateral sagittal split osteotomy is also preferred met#od 'ertical Corrections 1+ Ma*illary surgery a+ Superior repositio i g /to correct ope $ite+: =e:orte I used to mo)e ma*illa superiorly "#ic# allo"s ma di$le to autorotate a d correct ope $ite a d lo g face $+ I ferior repositio i g /to correct deep $ite+: Positio i g ma*illa do" "ard "ould rotate ma di$le ope to reduce o)er$ite a d le gt#e face !t#is is o e of least sta$le surgical procedures .+ Ma di$ular surgery !a terior a d do" "ard rotatio of ma di$le to correct deep $ite ca $e do e "% sagittal split osteotomy !surgical procedures to mo)e ma di$le superiorly to correct ope $ite are ;t recomme ded $%c cause do" "ard rotatio at go ial a gle a d stretc# muscles of pterygoma di$ular sli g

Transverse Corrections !for correctio of cross$ites6 ma*illa ca $e e*pa ded or co stricted duri g =e:orte I osteotomy !c#a ges i ma di$ular "idt# are more difficult 1+ Ma*illary e*pa sio : positio i g of lateral segme ts i ideal positio or $y use of surgically!assisted rapid e*pa sio !e*pa sio proceeds "% a 0ac3scre" de)ice .+ Ma*illary co strictio : $o e remo)ed to allo" for co strictio of lateral segme ts #enioplasty !c#i ca $e augme ted to impro)e est#etics $y osteotomy or addi g impla t material !slidi g osteotomy is preferred met#od a d ca $e used to mo)e c#i i all , dime sio s !reductio is least predicta$le met#od Timing of Surgery !surgery rarely performed $efore adolesce t gro"t# spurt e*cept i cases of facial deformity 1+ 9ro"t# e*cess cases /class III "% e*cess ma d8 gro"t#+: surgery s#ould $e delayed u til ma d8 gro"t# is complete .+ 9ro"t# deficie cy cases /class II "% small ma di$le+: surgery ca $e performed earlier i maturatio Se.uencing of Combined Surgical 1rtho Treatment 1+ Pretreatme t co sideratio s: disease co trol a d good gi gi)al #ealt# s#ould $e esta$lis#ed $efore t*t $egi s !u erupted%impacted ,rd molars s#ould $e remo)ed to allo" for good $o e #eali g .+ Ort#o t*t performed to alig teet# "it#i eac# arc# ,+ Surgery performed "it# ort#o applia ces i place !rigid "ires placed i applia ces to sta$ili>e teet# !0a"s repositio ed a d #eld $y rigid i ter al fi*atio or i terma*illary "ire fi*atio !soft diet re&uired for 7 "ee3s after surgery 1+ Pt retur s to co ti ue ort#odo tics for 7 mo t# period to detail occlusio a d fi is#