Enhanced CPD DO C Orthodontics

Ashwin Rao

Karuna YM, Shweta Tiwari, Radha Krishnan, Sonia Sivadas and Mansi Khare

Sectional Fixed Appliance Therapy

in the Mixed Dentition
Abstract: There are many common dental malocclusions seen in the mixed dentition, such as premature loss of, or retained, deciduous
teeth, submerged molars, supernumerary teeth, midline diastema, crossbites, increased overjet, open bites, ectopic eruptions and
crowding. In properly selected cases, like dental anterior crossbites or unerupted incisors, interceptive orthodontic treatment not only
improves function and aesthetics, but also achieves a relatively stable outcome, even after the removal of the appliance. A removable
appliance can be a mode of interceptive orthodontic treatment. The success of the interceptive treatment using a removable appliance,
however, depends upon patient compliance. In this regard, use of a sectional fixed appliance is gaining in popularity. This paper discusses
four case scenarios of malocclusion in the mixed dentition managed using sectional fixed therapy.
CPD/Clinical Relevance: The sectional fixed appliance is versatile, easy to use and well tolerated by patients. When used correctly, it gives
a more controlled approach to tooth movement in all three dimensions and a more predictable outcome.
Dent Update 2017; 44: 1083–1088

Common dental malocclusions seen in
the mixed dentition include premature
loss/over-retained deciduous teeth,
submerged molars, supernumerary teeth,
midline diastema, crossbites, increased
overjet, open bites, ectopic eruptions
and crowding.1 The available scientific
data suggest that malocclusions have
negative effects on oral health-related
quality of life, predominantly in the
dimensions of emotional and social
wellbeing.2 Interceptive treatment is thus
Ashwin Rao, Associate Professor, Karuna
YM, Assistant Professor, Shweta Tiwari ,
Postgraduate Student, Radha Krishnan,
Postgraduate Student, Sonia Sivadas,
Postgraduate Student and Mansi Khare,
Postgraduate Student, Department of
Paedodontics and Preventive Dentistry,
Manipal College of Dental Sciences,
Mangalore, Manipal University, India.
December 2017 DentalUpdate 1083
recommended in order to reduce the
severity of a developing malocclusion.
In properly selected cases, like dental
anterior crossbites or unerupted incisors,
interceptive orthodontic treatment not
only improves function and aesthetics,
but also achieves a relatively stable
outcome, even after the removal of the
appliance.3
Although a comprehensive
orthodontic finish without a second
phase of treatment in the permanent
dentition is not obtained in all cases,
carefully planned interceptive treatment
may help to reduce further orthodontic
treatment.4
A removable appliance can
be given as a mode of interceptive
orthodontic treatment. Wiedel and
Bondemark, through their randomized
controlled trial, concluded that anterior
crossbites during the mixed dentition
stage can be corrected using either
removable or fixed appliances with
equal success rate in terms of stability.5
However, removable appliances can
exert only single-point contact on teeth,
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leading to unsophisticated tipping
movements in most cases. In addition,
these appliances can be difficult for
the patients to fit and will not be worn
if they are either too loose or too
tight. Thus, success of the interceptive
treatment using a removable appliance
depends upon patient compliance, both
for wearing and adjusting the appliance.
The treatment will not work if this
co-operation is not forthcoming.6
In this regard, use of
sectional fixed appliances is gaining in
popularity. This appliance is versatile,
easy to use and well tolerated by all
patients. It also allows rapid correction
of many incipient malocclusions, with
a single short phase of fixed appliance
therapy in the early mixed dentition
stage.6
The fixed sectional appliance
The fixed sectional appliance
usually takes anchorage from the
maxillary molars and has brackets
bonded onto maxillary anteriors. The
 Orthodontics
Figure 1. Case 1: (a) Pre-treatment; (b) after surgical exposure; (c) active treatment started; (d) at 14 days of treatment; (e) stainless steel archwire and ‘E’
chain placed; (f) 4 weeks post stainless steel arch with ‘E’ chain placement; (g−i) post-correction.
number of maxillary anteriors to be
bonded varies according to the case.
The basic sectional fixed appliance
design has bands cemented on both
upper first permanent molars, brackets
bonded onto the erupted maxillary
incisors and continuous archwires to
provide/maintain good arch form, as
well as control of anterior teeth; 2 mm of
archwire that is left protruding from the
molar tubes should be annealed to allow
it to be turned down hard against the
tube. This step is important to prevent
the archwire sliding forward (except in
cases of anterior crossbite where it is
desirable), thus preventing increase of
arch length, trauma to the soft tissues
or loss of anchorage for the molars.
Supporting stainless steel tubing should
be ideally placed to strengthen the long
unsupported span of wire between the
molars and incisors. This protects the
archwire from distortion due to occlusal
forces.1
1084 DentalUpdate December 2017
When a fixed appliance
includes only some of the teeth,
archwire spans are longer. This gives
biomechanical advantages as large
moments are easy to create and the wires
themselves are springier. However, this
can lead to less strong appliances that
get broken or displaced or that cause soft
tissue irritation.7
The four cases outlined below
illustrate the effectiveness and versatility
of the appliance.
Case 1
A 13-year-old female patient
reported to the department with a chief
complaint of an unerupted tooth. Clinical
examination showed an unerupted
upper left central incisor (UL1) which
could be palpated clinically (Figure 1a).
She had a Class I molar relationship
on a Class I skeletal base. An intra-oral
periapical radiograph (IOPAR) showed
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no supernumerary teeth or any hard
tissue obstruction. The tooth UL1 was
exposed with an apically repositioned
flap and a straightwire bracket was
attached (Figure 1b). The molars were
banded. Five erupted anterior teeth
were bonded, and engaged with a
0.014” round nickel titanium (NiTi)
wire (Figure 1c). Two weeks later the
tooth was partially erupted (Figure
1d). A 0.02” round stainless steel wire
was engaged with a downward bend
and tooth UL1 was engaged in that
bend with an elastic thread (Figure 1e).
One month after this appointment,
the tooth UL1 erupted to its proper
position (Figures 1g−i). No retainers
were placed. The total treatment time
was one and a half months.
Case 2
A nine-year-old female
patient reported to our department
 Orthodontics
Figure 2. Case 2: (a−c) Pre-treatment; (d−f) commencement of the treatment; (g−i) mid treatment − after one month; (j−l) post-correction.
with the chief complaint of malaligned
teeth. Clinical examination showed
dental anterior crossbite with a
functional shift in relation to the upper
right central incisor (UR1) and the
upper left central incisor (UL1). She
had a Class III incisor relationship on a
Class I skeletal base (Figures 2a−c). A 2
x 2 fixed appliance was designed with
straightwire brackets and bands on
molars. A 0.014” round NiTi wire was
engaged (Figures 2d−f ). Though the
bite needs to be raised to disengage
the teeth in crossbite, it was not done in
this case as the crossbite correction was
progressing well at recalls, even without
the bite disengagement. The crossbite
correction was completed within one
month (Figure 2g−i). No retainers were
indicated in this case because of the
positive overjet, with normal overbite
1086 DentalUpdate December 2017
obtained post treatment (Figure 2j−l). first permanent molars. A 0.014” round
NiTi wire was initially engaged for one
Case 3 month followed by a 0.016” round NiTi
A 10-year-old male patient wire for another month. After the initial
levelling and alignment, a 0.02” round
reported to the clinic with a chief complaint
stainless steel round wire was then
of forwardly placed upper front teeth.
engaged and the teeth were retracted
Clinical examination showed proclined and
using an elastomeric chain from one
spaced anteriors. The ovejet was
side maxillary first permanent molar to
7 mm. There was no deep bite and
the other (Figure 3d−g). The maxillary
adequate vertical clearance was present
(Figure 3a−c). There were no skeletal incisors were retracted over one month.
A Hawley retainer was given to the child
discrepancies and no history of thumb-
to prevent relapse and the child was
sucking. Early treatment was indicated
put on a regular follow-up to modify
because of the potential for traumatic
the retainer whenever necessary during
injuries. When the option of treatment using
the transition from the mixed to the
removable appliance was given, both the
permanent dentition.
child and the parents did not prefer it. Thus
a sectional fixed appliance was planned by
bonding straightwire brackets on all four Case 4
maxillary incisors and bonding the maxillary A nine-year-old female
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Figure 3. Case 3: (a−c) Pre- treatment; (d−f) mid treatment; (g) Hawley retainer in situ; (h, i) at 3-month recall post-treatment.
patient reported with a chief complaint
of an extra tooth in the upper front
tooth region. On clinical examination,
a fully erupted mesiodens was seen
(Figure 4a−b). The mesiodens was
extracted under local anaesthesia
(Figure 4c−d). The resulting midline
diastema was 8 mm, the closure of
which required bodily movement of the
maxillary central incisors. A sectional
fixed appliance was placed involving
all the four maxillary incisors with a
0.02” round stainless steel wire and
an elastomeric chain between them.
Following space closure, frenectomy was
performed using a laser (Figure 4e−g).
The teeth were retained with a palatally
bonded retainer (Figure 4h).
Discussion
It is important to make an
annual assessment of patients in the
mixed dentition to identify developing
problems and, where necessary, to
December 2017 DentalUpdate 1087
initiate treatment or refer to a specialist.
Interceptive treatment can play a key
role because early treatment can, not
only correct the occlusion, but may also
encourage normal development of the
teeth and jaws.8
In this regard, the fixed
sectional appliance used in the mixed
dentition is an extremely versatile
appliance. There has been much debate
in the literature regarding the ideal
timing of orthodontic treatment.6
According to the guidelines laid down
by the British Orthodontic Society,
the majority of orthodontic treatment
can commence in the late mixed and
early permanent dentition. However,
earlier referral is needed in certain
circumstances when interceptive
treatment is indicated.9 While
undertaking interceptive treatment,
diagnosis and treatment planning play
a key role and are as important as in
comprehensive treatment.7
Early intervention can
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Orthodontics
simplify or eliminate the need for later
treatment.8 The main advantage of
early treatment in properly selected
cases is that it not only quickly restores
anterior aesthetics, but may also reduce
the complexity and duration of any
subsequent treatment required. Rotations
and diastemas, as well as incorrect tooth
inclinations and angulations, may therefore
be treated quickly using this versatile
technique.6
However, in complex mixed
dentition cases, a second stage of treatment
in the early permanent dentition may be
required, in spite of effective treatment in
the mixed dentition. Hence, final finishing
and root positioning is not indicated in
most of the interceptive cases. Long spans
of treatment can result in ‘burning out’
of the patients, as well as damaging the
teeth and the supporting structures. Thus,
while treating the malocclusions in the
mixed dentition, it is important to have well
defined goals and endpoints which should
include appropriately planned treatment
 Orthodontics
Figure 4. Case 4: (a, b) Pre-treatment; (c, d) extraction of supernumerary tooth; (e, f), laser frenectomy; (g) 4. King GJ, Brudvik P. Effectiveness of
closure of midline diastema; (h) retention appliance in situ.
course, duration and mode of retention.7
During the course of fixed
sectional appliance therapy, it is
important to obtain radiographic images
routinely, especially while moving lateral
incisors that are adjacent to unerupted
canines. Care must be taken so that
the roots of the lateral incisors are not
inadvertently tipped into the path of
the erupting canines. It is also important
to check for the unerupted teeth
radiographically, as presence or absence
can alter the course and direction of the
treatment.7
The final stage of transition
from mixed to the permanent dentition
is an unstable period. Thus, once the
treatment is complete and desired results
have been achieved, retention must be
planned, keeping in mind the patient’s
current versus initial dentition status, as
well as subsequent changes in dentition
1088 DentalUpdate December 2017
and occlusion that will occur as the child
matures.7
Summary
The decision to use fixed
appliance sectional therapy over removable
appliance therapy as a mode of interceptive
orthodontic treatment should be judiciously
made after considering treatment needs
and patient compliance.
Cases selected for early
orthodontic interventions should have well
defined goals and endpoints of treatment.
References
1. Kamatchi D, Vasanthan P, Kumar SS.
Orthodontic challenges in mixed
dentition. SRM J Res Dent Sci 2015; 6:
22−28.
2. Dimberg L, Arnrup K, Bondemark L.
The impact of malocclusion on the
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quality of life among children and
adolescents: a systematic review of
quantitative studies. Eur J Orthod
2015; 37: 238−247.
3. Dowsing P, Sandler PJ. How to
effectively use a 2 x 4 appliance.
J Orthod 2004; 31: 248−258.
interceptive orthodontic treatment in
reducing malocclusions. Am J Orthod
Dentofacial Orthop 2010; 137: 18−25.
5. Wiedel AP, Bondemark L. Stability
of anterior crossbite correction: a
randomized controlled trial with a
2-year follow-up. Angle Orthod 2015;
85: 189−195.
6. McKeown HF, Sandler J. The two by
four appliance: a versatile appliance.
Dent Update 2001; 28: 496−500.
7. Treatment in preadolescent children:
what is different? In: Contemporary
Orthodontics 5th edn. Proffit WR,
Fields HW, Sarver DM, eds. Missouri:
Mosby, 2013: pp391−394.
8. Shaw WC, Meek SC, Jones DS.
Nicknames, teasing, harassment and
the salience of dental features among
school children. Br J Orthod 1980; 7:
75−80.
9. British Orthodontic Society. Guidelines
for Referrals for Orthodontic Treatment.
Guidelines available online from
http://www.bos.org.uk (Accessed 9
January 2015).