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Dr. Mariam Orthodontic Removable appliances (2) — Transcript

by Dr. Mariam Al-Abdallah · 9,100 words · 1,551 segments · language en · Watch on YouTube

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0:03As-salamu alaykum. This is Dr. Maryam Al
0:05Abdullah and we're going to
0:08continue our talk on removable
0:11appliances in orthodontics.
0:13Just to remind you with our reference,
0:15it's chapter 17 from an introduction to
0:18orthodontics.
0:21Last lecture we talked about definition
0:24of removable appliances, mode of action,
0:27indications, general design, started
0:30talking about active components and
0:32retentive components.
0:34Now, we're going to finish the rest of
0:35the components,
0:37talk about the management of removable
0:39appliances, and then show you some
0:42clinical cases.
0:45So, as we said, the components
0:48uh of removable appliances
0:50uh are active components, retentive
0:52components,
0:54anchorage considerations, and then base
0:56plates.
0:57Yeah?
0:59Some components may contribute to more
1:01than one function.
1:04Now, let's talk a little bit about
1:06anchorage. When we say anchorage, it's
1:08not It's not like a specific
1:10uh
1:11component like the uh Z spring or
1:14braided finger spring
1:16uh
1:17or Adams clasp.
1:18Anchorage is
1:21a concept. It's the resistance to
1:23unwanted tooth movement.
1:26In orthodontics, we apply pressure or
1:29force to the teeth.
1:31So, this is what we consider action.
1:33According to Newton's third law, there
1:36is a reaction for every action.
1:40The reaction to the orthodontic force is
1:43sometimes undesirable. So, we need to
1:45resist unwanted tooth movement produced
1:49by this action.
1:50And this is how we measure anchorage.
1:53Now, the way to do it is to look at the
1:56tooth or teeth that we are trying to
2:00move.
2:01The
2:03root surface area of these teeth will
2:07tell us about the reaction amount of the
2:11reaction that we want to resist.
2:14So, we have teeth that we will move and
2:18teeth that should stay still.
2:20The teeth that we want to move are
2:22called the active unit.
2:24The teeth that should stay still are
2:26called the anchorage unit.
2:29Now, to be able to control anchorage, we
2:32have to have as little as possible in
2:36the active unit as as much as possible
2:39in terms of number of teeth, more root
2:42surface area in the anchorage unit.
2:47Another thing to do is to divide and
2:50conquer concept, which means that
2:52instead of moving three or four teeth at
2:55the same time, we can go with two stages
2:57of treatment.
2:59Where we move one or two teeth in the
3:01first stage of treatment and then a
3:03second stage to move the rest of the
3:05teeth
3:06according to the treatment plan.
3:11Also, anchorage could be reinforced in
3:13orthodontics by using other appliances.
3:17For example, like the headgear that we
3:20talked about in our last lecture. It's
3:23an extraoral appliance that could be
3:26used to reinforce anchorage.
3:29There are different concepts regarding
3:31anchorage and this will be explained in
3:33details in a separate lecture. But,
3:35since we're talking about it in the
3:37removable appliances, it's really
3:41sometimes part of the design of the
3:44acrylic and its contact with teeth. We
3:47will cover a little bit on that of when
3:50we talk about the base plate.
3:53So, the uses of the base plate is to
3:56incorporate both retentive and active
3:59components into a single functional
4:01unit.
4:02So, it holds the metal framework all
4:05together.
4:06It also helps in anchorage and retention
4:10of the appliance in the mouth.
4:12It should resist unwanted drift during
4:14tooth movement, and it distributes the
4:16forces from the active components over a
4:19large area.
4:21This large area could be the teeth that
4:24should stay sound that you talked about,
4:26and this will depends on this should
4:28depend on the uh root surface area. The
4:32larger the root surface area, the more
4:34anchorage we get from these teeth.
4:37It also depends on the uh surface area
4:40of the acrylic and
4:43uh what it covers
4:45uh vertically and horizontally in terms
4:47of the anatomy of the palate.
4:52Base plate also protects the palatal
4:54springs against distortion in the mouth.
4:56We said that sometimes the active
4:58components could be made of 0.5 mm
5:01stainless steel wire, and this is a
5:02small thickness,
5:04and it could be distorted. And as And
5:06one way to protect them is to build
5:09um
5:10acrylic as a box
5:12to uh prevent
5:14uh distortion
5:16and breakages.
5:19Uh sometimes we can modify the base
5:21plate to play an active role like bite
5:23plane.
5:25Steer bite plane or anterior bite plane.
5:29Uh
5:31the base plate is usually made of
5:34self-cure acrylic.
5:37Um because it's cheaper and it's
5:40quicker to be made
5:42uh although there is more free monomer.
5:45And the reason why we choose for the
5:47majority of our removable appliances
5:49self-cure acrylic is
5:52uh because these appliances are usually
5:54made to be used for a very limited time,
5:58for example, 6 months,
5:599 months.
6:01And uh they usually produce uh light
6:04forces and they are uh exposed to
6:09light acceptable amount of force.
6:12But, if I'm planning to use the
6:14appliance for a longer time or the
6:16appliance is expected to be
6:19uh exposed to heavy force, then we need
6:23to go for heat-cured acrylic to give an
6:26additional strength to the appliance.
6:31Anterior bite plane is one of the
6:33modifications that we could apply to the
6:35base plate.
6:36And what do we do is to increase the
6:39thickness of the acrylic behind the
6:40upper incisors.
6:43We increase the thickness by increasing
6:45the depth and increasing the length of
6:48the uh
6:49of the of the piece of acrylic that is
6:51behind the upper incisors.
6:54And when the patient
6:56uh when the patient's trying to go for
6:58maximum intercuspation, usually the
7:00lower incisors will bite on this bite
7:04plane and the buckle segment is
7:06separated.
7:08Uh to have a proper bite plane being
7:10built up, we have to have at least
7:13three incisors in contact with this bite
7:16plane out of four. Because if we have
7:19one or two only, then there will be a
7:21traumatic bite and we will have
7:23mobility, root resorption, gingival
7:25recession affecting the lower incisors.
7:28So, to have a proper distribution of
7:30forces um resulting from biting on this
7:34bite plane,
7:36it's important to have three of the
7:38incisors at least out of four comes in
7:41contact with the spike plane during
7:43maximum intercuspation.
7:45Um what do we use it for? As you can
7:49see, the lower incisors comes in contact
7:52with the spike plane, and what happens
7:53to the buckle segment is that they
7:55become separated. And now in growing
7:58patients, they are free to erupt to fill
8:01this gap, and we will end up with
8:03reducing the overbite. So, it is used in
8:06growing patients with deep overbite.
8:09increased overbite because it's very
8:12useful, and it's
8:14um
8:15uh it's an effective way to reduce the
8:18overbite.
8:19Uh another way uh another um
8:22situation where we need an anterior bite
8:24plane is to free the occlusion to allow
8:27tooth movement. Sometimes the occlusion
8:30can prevent the wanted tooth movement.
8:33So, we can separate the teeth. We can
8:36open the occlusion using flat anterior
8:38bite plane.
8:41Um the uh
8:44bite plane should be flat. Otherwise, if
8:46it's inclined to a certain
8:48uh direction, it will affect the lower
8:50labial segment, and it will cause
8:52unwanted movement, unwanted movement.
8:57So, this is an example of a patient with
8:59a classical class two division two
9:01malocclusion, deep overbite, and uh if
9:06we want to
9:08uh insert
9:10lower fixed appliance with this amount
9:13of bite, it's not possible.
9:15So, what do we do? We add uh a first
9:18stage of removal appliance with a flat
9:21anterior bite plane.
9:23And
9:25this is
9:27what happens. What happens is that the
9:29overbite is reduced, and now we can fit
9:31the lower fixed appliance and move on
9:33with the rest of the stages of the
9:36uh treatment.
9:38What
9:39does the technician need
9:41need to know? Well,
9:43in order to build a proper bite plane, a
9:46clear bite plane, we should inform the
9:48technician about the amount of overjet
9:51because the amount of overjet will uh
9:56determine the amount of uh
9:59bite plane extension posteriorly.
10:02The length of the bite plane, how long
10:04it should go posteriorly.
10:06The bigger the overjet, the longer the
10:10extension of the bite plane posteriorly
10:13to allow the lower incisor to bite on
10:15it.
10:16Also, the technician needs to know the
10:17amount of overbite.
10:19The amount of overbite is important
10:21because you can only separate the buckle
10:24segments uh 2 to 3 mm. You cannot
10:28separate it more than that because the
10:30appliance will be uncomfortable and the
10:33patient will not wear it.
10:35So, if the overbite is really deep, then
10:38we can have a two stages of
10:41uh uh uh of removable appliances. The
10:44first stage where we have uh enough
10:48depth
10:48of the bite plane to separate the buckle
10:51segment 2 to 3 mm and then the buckle
10:54segments uh erupts into that space and
10:57come come in contact with the other uh
11:00molars, then we add a new layer of
11:04acrylic. We build further the anterior
11:08bite plane so that we will have another
11:102 to 3 mm of separation.
11:12And so on and so forth until we get a
11:14proper overbite reduction for those
11:17patients.
11:19Buckle capping is another modification
11:21for the base plate
11:23where we cover the occlusal surface of
11:27the
11:28uh of the buckle teeth.
11:30Uh sometimes we cover it fully or we
11:32cover half of the
11:36uh, of the buckle cusp.
11:37Uh, sorry, only the palatal cusp and we
11:39free the buckle cusp. Uh, the reason why
11:41because it will make it easier to adjust
11:44the rest of the components if it's only
11:47halfway uh, coverage of the occlusal
11:49surface.
11:51Why do we need to use it? Well, it is
11:54used to open the bite to allow tooth
11:57movement.
11:58So, this is an example of a patient that
12:00has a unilateral buckle crossbite with
12:03mandibular displacement. So, if we want
12:06to expand the upper uh,
12:09arch using midline expansion screw, this
12:13occlusion locks the buckle segment and
12:16prevent its movement. So, what do we do
12:19is that we add um, posterior capping or
12:23what we call posterior bite plane.
12:26And then, as the patient activates the
12:28midline expansion screw, the teeth can
12:30bypass each other and the occlusion is
12:33not locked and we can correct the
12:35malocclusion.
12:37Um,
12:39the
12:41posterior bite plane should be
12:43thin enough to be comfortable, but thick
12:46enough to be strong and
12:50uh,
12:51avoid uh, breakages.
12:54Uh, the patient should be warned about
12:57uh, fracture. They should be given
12:58instructions on diet
13:00and eating that we will talk about this
13:03when we talk about the removal of
13:04appliance management.
13:08So, it should cover the posterior teeth
13:10so that the anteriors are only separated
13:132 to 3 mm. So, it should not be thick. A
13:16thick face blade will cause discomfort,
13:19a bigger separation of the anterior
13:20teeth.
13:22Um,
13:23as we said, it could be extended only
13:26halfway across the buckle segment to
13:28assist adjustment of other components
13:30like Adams clasp.
13:34And this is an example
13:35of an upper removable appliance with
13:39midline expansion screw.
13:41The wanted tooth movement is to push
13:44both buckle segments on the right and on
13:46the left buckle.
13:48And if there is occlusal interference,
13:52then we extend the acrylic to cover the
13:55occlusal surface of the buckle segment
13:57like this. So, this is a posterior bite
13:58plane
13:59incorporated into this design.
14:03So, when I want to design a removable
14:06appliance, I have to go through um
14:10a specific thinking process.
14:13The first thing is
14:15is this the case that can be corrected
14:19with simple tipping movement?
14:22I need to know the limitations of my
14:24appliance. Removable appliances can only
14:26produce simple tipping movement. If this
14:29can correct the features of malocclusion
14:31that the patient is presented to it,
14:33then we can use this appliance for this
14:36patient.
14:37We have to have proper records,
14:39especially impression with alginate in
14:42order to construct um
14:45a removable appliance that can fit
14:47uh accurately inside the patient's
14:49mouth.
14:51Now, when I when I think about the
14:53actual design, the first thing I need to
14:56choose is the active components.
14:59So, I need to know why I'm using this
15:02appliance.
15:03What teeth do I want to move and in what
15:06in which direction?
15:09Uh and accordingly, I go for my active
15:12components. So, for example, I have a
15:14premolar in crossbite and I want to push
15:18this tooth across the
15:21occlusion buccally, then I choose the
15:24spring.
15:26T spring.
15:28Uh for example, if I want to distalize
15:32the molars on one side, then I use
15:35expansion screw. And so on. So, you have
15:38to know what are you aiming for, and
15:40then you choose your accurate active
15:42component.
15:44After that, you decide on your retentive
15:46components. As we said, retentive
15:48components, the main aim is to retain
15:51the appliance in place.
15:53It's important to have at least the
15:54three points of retention. If you have
15:57abrupt heavy force, like for example, in
15:59cases of expansion screws, then you have
16:02to use four points of retention.
16:05Now, it's important also to choose your
16:07retentive components so that they do not
16:09interfere with the movement of teeth.
16:13Uh again, for example, I'm using a Z
16:15spring on the upper left central
16:17incisor, I cannot use a south end on
16:22both central incisors
16:24because one of them is going to be moved
16:26buccally. So, this is an interference.
16:28This is This cannot work.
16:32Right. Now, after that, I need to think
16:35about the anchorage management in that
16:37case.
16:38I need to know how many teeth I'm trying
16:41to move, how many teeth are in my active
16:44unit, how many teeth are supposed to
16:46stay still, which means the teeth that
16:48are in my anchorage unit, and if I need
16:52to reinforce anchorage using, for
16:54example, headgear or dividing the
16:57the treatment instead of one stage, two
17:00stage
17:02two stage removal appliance treatment,
17:05etc.
17:08And finally, we decide if my acrylic
17:11needs modification by adding anterior
17:14bite plane or posterior bite plane.
17:18So, we take the uh the impression, we
17:20pour the stone, we have a study model,
17:22metal framework is
17:25constructed on this study model, then
17:27acrylic is added to combine and to hold
17:31the framework the metal framework
17:33together. We modify it accordingly.
17:37And then we have our appliance.
17:39Now, I want to fit the appliance inside
17:41the patient's mouth.
17:43I need tools. I need instruments to be
17:47ready in my clinic. I need Adams pliers
17:50to adjust
17:52uh the different components or loop
17:54forming pliers, also to adjust the uh
17:57active and the retentive components. I
17:59need a cutter heavy cutter.
18:01Um I need a ruler and a divider in order
18:04to measure references, um
18:09distances, etc. to make sure that uh
18:13uh I have a good occlusal line in adult.
18:16And of course, I can use a straight
18:18handpiece with an acrylic bur in case I
18:21needed to
18:22adjust or modify the acrylic.
18:25For example, if I
18:27uh discovered that the acrylic is in the
18:31way of tooth movement,
18:33in the path of tooth movement there is
18:35an excess acrylic, then I I need to trim
18:37it.
18:38Uh
18:39for example, an anterior bite plane
18:42uh
18:42as we said should be in contact with at
18:44least the three lower incisors. So, I
18:46take an articulating paper and I ask the
18:49patient to bite, and then if there is
18:51only two out of three, then I have to
18:53trim the acrylic until I get at least
18:56the three lower incisors in touch with
18:58the uh flat anterior bite plane.
19:03When I receive the appliance from the
19:05lab, I need to make sure that this is
19:07the design that I requested. And this is
19:09the the model for that patient who's
19:12sitting on in the chair.
19:15I need to make sure that the fitting
19:16surface is
19:19um
19:20uh having no roughness or bubbles or any
19:23problems that could could disturb the
19:25patient.
19:27And after that, before I try the
19:29appliance inside the patient's mouth, I
19:31have to show the patient the appliance,
19:34explain about the different components,
19:36and ask his permission to try it in.
19:40And after we fit the appliance, then we
19:42give the patient and the parents
19:44instructions about how to take care of
19:46the appliance, how to fit it, how to
19:47take it out, etc.
19:51Now, if I try it in and it's not
19:53fitting,
19:54okay? Not fitting doesn't mean not
19:56retentive. Not fitting, it means for
19:58example it's rocking.
20:00The problem could be that there is
20:01partially erupted teeth when I took the
20:04impression, and now when I want to
20:06deliver the appliance, it erupted a
20:09little bit further, and now it's
20:11interfering with the acrylic.
20:13And I use the straight hand handpiece
20:15with the
20:16uh the straight handpiece with the bare
20:18acrylic bare in order to remove such
20:21uh an interference.
20:22Maybe a tooth has moved
20:25uh by the time the appliance has
20:26arrived.
20:27If there is significant delay between
20:29taking the impression and fitting it,
20:31especially if the patient is still
20:33growing, then it there is change there's
20:36a general change in the dental uh
20:39in the dentition,
20:40uh teeth, soft tissues, etc. So, it will
20:43not fit.
20:45And after that, I check retention. So,
20:49the first thing, check uh if it's
20:52fitting or not, and then I check
20:53retention, and I adjust the retention
20:56until the appliance is retentive inside
20:58the patient's mouth.
21:01I adjust the bite plane as necessary,
21:04and finally, we adjust the active
21:06components. Sometimes the active
21:08components are left passive for the
21:11first visit until the patient gets used
21:15to the
21:16appliance and then the next visit we
21:18start activation. This depends on the
21:20case, on the patient's age, patient's
21:23compliance and cooperation.
21:26Um
21:29and accordingly I decide on this step.
21:33Uh of course, when I'm sure that
21:35everything is good, I give the patient a
21:37mirror and I ask him to look through it
21:39and then I start to insert the patient
21:41with the
21:43insert the appliance inside the
21:44patient's mouth and I I
21:48I use the technique of show and tell.
21:50So, he has to look at himself inside the
21:52mirror and see how we fit the appliance
21:55and how we remove it.
21:58Now, the instructions should again it
22:01depends on the appliance. Do I want the
22:03patient to wear it full time?
22:05Do I want the the patient to wear it
22:07part time? Is it a gradual increase of
22:09the time of wearing it? Uh
22:12do we have an expansion screw that the
22:14patient is responsible to open? So, the
22:16instructions depends really on the
22:18appliance and on the case.
22:20And before the before the patient
22:22leaves, he should know when his next
22:24appointment for review.
22:26So, the instructions is that the
22:29appliance is not maneuvered uh through
22:32the labial bows
22:34uh or springs. If you want to take it
22:37out, it's important to go to the
22:40posterior bridges uh Adams clasp for
22:43example, something rigid, okay? Because
22:46labial bows springs will be disturbed if
22:48the if the patient starts to remove the
22:50appliance using them.
22:52Now, some appliances the patient should
22:54wear full time, 24 hours during school
22:57hours, at night, sport as long as it's
23:01not contact sport, he can wear it. Uh
23:04the only time he is not allowed to wear
23:06his appliance is if if the patient is
23:08going for swimming or contact sport.
23:11Uh swimming because the color of the
23:13appliance will
23:15uh make it difficult for the patient to
23:17look for it if it will if it is removed
23:19from his mouth during swimming.
23:21And contact sport it's a bit dangerous
23:23and it can cause trauma.
23:26Uh
23:28as I said, yes, appliances Some
23:30appliances the patient can wear 24 hours
23:32and some appliances the patient should
23:33wear uh
23:36for example, all time except for meals
23:38uh or night time and
23:41uh
23:42night time and uh
23:45evening, sorry, evening and all night.
23:47It depends on the appliance.
23:49Of course, high standard oral hygiene
23:51should be insisted. If the patient
23:52should wear the appliance full time,
23:54then he should avoid sticky food, hard
23:56food, and he should remove the appliance
23:58after meal, brush his teeth, clean his
24:01appliance, and fit it back in again.
24:06Uh it is uh it is expected to have some
24:10uh
24:12uh tooth aches, headaches
24:15uh due to pressure on teeth and movement
24:18of teeth. So, the patient can take pain
24:20killer based on his weight and age. Um
24:24some components can cause at the
24:26beginning ulcers because these are new
24:28inside his mouth, so he can use uh gels
24:31for uh
24:33oral gels for uh ulcers.
24:36And this is temporarily. If it persists,
24:39then the patient should uh contact the
24:42clinic and uh arrange an appointment.
24:45I need to give the patient instructions
24:47on how to activate the screw if it's
24:49part of the appliance.
24:51It's very important that if the patient
24:53is wearing the appliance part time, not
24:55full time, to have a proper container or
24:57case in order to keep the appliance
25:01there. Otherwise, if it's if it's left
25:04outside the mouth, it can break, it can
25:06be lost, and he will need to construct a
25:09new one.
25:11Usually, the review, again, depends on
25:13the case, but it ranges between 1 month
25:16to 3 months.
25:18Now, when the patient comes back to his
25:20review clinic, I can tell if the patient
25:24is actually not wearing his appliance.
25:27Um I check the appliance, and I find
25:30little evidence of wear.
25:32Uh if I ask the appliance about uh how
25:36he's been doing, how is the appliance,
25:38and he has he he's been talking not
25:41without any proper pronunciation, not
25:44proper speech, that means the appliance
25:46was not inside his mouth properly.
25:48Uh if I check intraorally and there are
25:51no marks around the different components
25:54of the appliance on the palate, that
25:55means he's not been wearing it. If the
25:58appliance is experiencing frequent
26:00breakages, that means it's being outside
26:02his mouth more than inside his mouth.
26:06And, of course, if I look inside the
26:08mouth and I examine the teeth that I
26:09wanted to move and there is no progress,
26:12that means the patient is not compliant.
26:14At each visit, I have to check oral
26:18hygiene, I have to measure overjet,
26:21overbite, molar relationship, and
26:24compare these with the baseline measures
26:28and relationships.
26:30I need to check loss of anchorage, and
26:32usually loss of anchorage is expressed
26:35by increasing of the overjet.
26:38Um
26:40or movement of the anchorage unit uh
26:44toward the uh the active components.
26:50So, for example, if I want to push the
26:52labial segment buckley, the reaction is
26:55that the buckle segment will be pushed
26:57distally.
26:58So, I need to check the molar
26:59relationship and check loss of
27:01anchorage.
27:04I need, of course, to check tooth
27:05movement and I I can measure uh
27:10the distance
27:11uh from the tooth that I want to move to
27:14the the tooth that is is supposed to be
27:16stay still and I compare that with the
27:18baseline. For example, I'm trying to
27:20distalize the canine, then this distance
27:23here should be it should get smaller
27:26every visit.
27:27I need, of course, to check the
27:29retentive components and it's it's
27:31normal to have an appliance that is
27:33loose
27:35because the patient is supposed to leave
27:37it to remove the appliance after meals
27:39to clean it.
27:40Uh so, I check the retentive components
27:43and retighten them, reactivate them. I
27:45need to check active components and
27:47again activate them accordingly. I need
27:50to check the bite planes and and the
27:51buckle capping for any fractures or
27:53breakages, and then I need to
27:57uh decide on my next visit aims and give
27:59the patient a review appointment and so
28:01on and so forth.
28:03If the patient is experiencing slow rate
28:05of tooth movement, then maybe the
28:07patient is not really wearing the
28:08appliance full time as instructed.
28:12Uh maybe the springs, the active
28:14components, are not correctly
28:16positioned.
28:17Or maybe the active components are being
28:19distorted or over activated.
28:22Uh maybe the acrylic is in the way of
28:25the tooth uh path of movement and so
28:28that it's it's preventing tooth
28:29movement.
28:31Sometimes the occlusion prevent the
28:33movement.
28:35The occlusion can prevent some sometimes
28:37of tooth movement and this is why using
28:40some
28:41uh
28:42plates with the acrylic can help to
28:43disocclude teeth.
28:46If the patient is experiencing frequent
28:48breakages, then again maybe because the
28:50patient is not wearing the appliance
28:52full time.
28:53Uh maybe the patient is having the habit
28:55of clicking the appliance in and out
28:58with his tongue. Usually the the patient
29:01when he gets used to
29:02the appliance, he will go with his
29:04tongue, suck it out, suck it in, suck it
29:06out, suck it in until
29:08uh the components are uh fragile and we
29:12have fatigue
29:14uh within the different components and
29:15then we will have breakages.
29:18Uh or the patient is not following diet
29:20and restrictions and he's eating sticky
29:22food and hard food and this might break
29:24the appliance.
29:27Again, if the appliance is getting
29:29quickly loose, so for example, I give
29:31the patient a 3-month appointment and he
29:33comes 1 month uh later saying that it's
29:36loose, it comes out of his mouth. Then
29:39maybe the patient is playing with the
29:41appliance, clicking it in and out.
29:44Uh and or he's removing the appliance
29:46frequently.
29:47Uh
29:49Uh
29:50every time he's being disturbed, the
29:52patient is feeling a bit of pain, he
29:53removes the appliance and this is why
29:56the retentive components becomes loose.
30:00Uh
30:01if the patient is experiencing excessive
30:03tilting of tooth that I'm trying to
30:06move, maybe the force is excessive.
30:09Maybe the active components are being
30:11distorted.
30:13Uh or maybe the force is further away
30:16from the center of resistance.
30:18Uh
30:19my aim is to have the force as close as
30:22possible to the center of resistance to
30:24have a controlled tooth movement.
30:28Again, anchorage loss.
30:30Uh
30:31we worry about anchorage loss especially
30:33for patients who's not wearing his
30:35appliance as instructed. They should
30:37wear it full time. Part-time wearers can
30:40experience uh anchorage loss.
30:42Uh or maybe the anchorage was not
30:44properly planned.
30:47Uh
30:48an example, for example, I'm trying to
30:50distalize the canine.
30:52So, the canine should be distally moved.
30:54The reaction is that the anterior
30:56segment moves anteriorly.
30:58So, if I have proper anchorage, the
31:00overjet should not change over the
31:02visits. If it increased, that means I
31:05have loss of anchorage.
31:07The anchorage is not properly planned or
31:08the patient is not wearing the appliance
31:10as instructed.
31:13Sometimes the patient in experience
31:15blatant inflammation due to poor oral
31:17hygiene.
31:19Or maybe the fitting surface is causing
31:22trauma to the palate.
31:25Uh
31:26or maybe the gingiva is being trapped
31:28between the acrylic at the and between
31:30the tooth that I'm trying to move.
31:34If the overbite that I'm aiming to
31:37reduce with a flat anterior bite plane
31:39is not responding, maybe because the
31:42patient has stopped growing because um
31:45I'm planning this
31:48uh
31:49aim only in growing patients, okay?
31:52Uh maybe the patient is having a
31:54horizontal mandibular growth
31:56in in instead of a proper rotation.
31:59Or maybe the patient is not wearing his
32:00appliance.
32:03Now,
32:04if the appliance experienced fracture, I
32:07need to know why it was fractured. And I
32:09need to give the patient the
32:11instructions to avoid this incident.
32:14I need to think about the cost of making
32:17a new one or repairing the old one.
32:20I need to look at the broken part.
32:24Is it
32:25um a part that I can actually
32:27avoid using at that stage? For example,
32:30if I have breakage of one of the outer
32:32hits of the Adams,
32:34I cut the sharp arm.
32:36Uh and then I look at the other side of
32:38it. Is it enough to give me the
32:39retention? If it if the appliance is
32:41retentive, there is enough retention,
32:42then I just adjust and reinsert.
32:47Uh if the original study model is there
32:51and it could be useful for
32:54repair, then I can place the appliance
32:56on the study model and send it to the
32:58lab for repair. Otherwise, I have to
33:01insert the appliance inside the
33:02patient's mouth and I take an over
33:04impression with the alginate. So, I take
33:06the impression and the whole appliance
33:08will come out with the impression and I
33:10send it to the lab for repair.
33:14Um the repair should not take a long
33:17time
33:18uh because I already have a a teeth or a
33:20tooth that is
33:23uh being moved, so I don't want to have
33:25relapse and I need the appliance to come
33:27back as soon as possible so that it can
33:29fit properly and continue my treatment
33:31plan and continue my tooth movement.
33:33Now, we're going to talk about some
33:35clinical cases to apply this knowledge
33:38about URA design.
33:42We're going to start with a single
33:43anterior tooth in crossbite.
33:46So, this is a patient in the mixed
33:48dentition. The only problem I want to
33:50worry about here, the only problem, the
33:53only feature of the malocclusion is the
33:56upper right central incisor in
33:58crossbite. Okay?
34:00So, can I correct this with simple
34:02tipping movement? Yes. So, this is the
34:04first question. The second question is
34:08what active component can
34:12fulfill this aim? Well, for a single
34:14tooth in crossbite in the anterior
34:16segment where I want to push labially, I
34:19can use the spring.
34:22Okay. What about retentive components?
34:26Once I decided on my active component, I
34:28can decide on my retentive components.
34:31So, the retentive components could be an
34:34Adams clasp on the upper left six. So,
34:38the upper left six
34:39uh
34:40we can have Adams
34:42clasp .7 mm stainless steel wire. So,
34:45this is how we communicate with the uh
34:48technician. We need to write the name of
34:51my component and I need to draw it.
34:54So, I'll have a Z spring on the upper
34:57right central incisor, Adams clasps on
35:01the upper left
35:02six, upper right six, and upper right
35:05four because here the patient is having
35:07a four fully erupted, so I can use it.
35:11Um and of course, because I'm trying to
35:14push a tooth across the bite, the
35:16occlusion will prevent this, so I need
35:18to add posterior bite plane.
35:20Okay?
35:21Um can I use labial bow? Um you can use
35:25sure, we can use short labial bow, but
35:27why if I'm having my third point of
35:29retention posteriorly, and this will aid
35:32um let's say
35:35uh aesthetic. The patient will
35:37appreciate it that you're not using
35:39anterior components.
35:41Uh
35:42and this will aid patient's compliance
35:43as well.
35:46So, this is how we draw the posterior
35:47bite plane, and this is how we
35:49communicate with the technician
35:51regarding the design. Okay? I write the
35:54name of my active component, where I
35:57want to put it, and the thickness of the
35:59wire. Z spring force is .5 mm stainless
36:02steel wire, Adams on the molar is .7 mm
36:06stainless steel wire, on the premolar .6
36:08mm stainless steel wire.
36:11Just to remind you, this is how a Z
36:14spring will look like inside the
36:16removable appliance. It's a .5 mm
36:19stainless steel wire.
36:21This is the general idea. Now, these
36:23teeth are colored blue because there is
36:25a bite plane.
36:27So, when we activate the Z spring, it
36:29should push
36:30the tooth across the bite and correct
36:34the anterior crossbite.
36:36Now, this is the patient before
36:38and this is the patient after. And this
36:40is the only feature I'm trying to
36:42correct, just simple tipping movement. I
36:45would not use the removable appliance
36:46for rotational movement because it's not
36:49possible.
36:51Another case is a patient with two
36:53adjacent anterior teeth in crossbite
36:56like this.
36:57So, again
36:59the first question, can I correct this
37:00with simple tipping movement? Looking at
37:03the teeth and their orientation, yes, I
37:04can.
37:06Uh what is the active component that can
37:08produce such movement? Well, again, it's
37:11a Z spring, double cantilever modified
37:14so that it the active arm is longer and
37:18we modify the thickness and use 0.6 mm
37:21stainless steel wire.
37:25And after that, I decide on the
37:27uh
37:29retentive components.
37:31So, I'll have a double cantilever on on
37:34the central incisors to correct the
37:35anterior crossbite. This is 0.6 mm
37:38stainless steel wire.
37:40I can have double Adams on the sixth and
37:42the uh the E. You can see this is the E.
37:45On the sixth and the E and this is a 0.7
37:47mm stainless steel wire.
37:49And then Adams on the upper
37:51uh
37:52right six
37:530.7 mm stainless steel wire and another
37:56Adam.
37:58Uh sorry, there were 1 2 3. Oh, yes,
38:00this is enough. And then we can use
38:02another Adam on the upper uh
38:04right four of 0.6 mm stainless steel
38:07wire.
38:09And of course, because the teeth are in
38:11crossbite and the occlusion will prevent
38:14their movement, it's important to go for
38:16posterior bite plane.
38:20So, this is a reminder of the
38:23active components. So, we have double
38:25cantilever.
38:26Some books will use
38:28um
38:29separate Z springs, one on the left
38:31side, one on the right side. Well, this
38:33is not being advised because if you have
38:37diff- a little bit of different
38:38activation between these two centrals,
38:40the patient will not appreciate to have
38:42two centrals uh
38:45of different position. Okay? Uh one
38:48double cantilever will you will activate
38:50it
38:51uh
38:52at once and it will move the teeth
38:54equally.
38:55And it should not produce different
38:57tooth position at the end of the
38:59treatment.
39:01So, this is the patient with a crossbite
39:04before and this is after and only simple
39:07simple tipping movement was used.
39:10Another case is when you have more than
39:13two anterior teeth in crossbite.
39:15If you have more than two anterior teeth
39:18in crossbite, you cannot use Z spring or
39:20double cantilever. You have to use
39:23something else. It is the anterior
39:26expansion screw because now you want to
39:28move blocks of teeth.
39:31So, we use anterior expansion screw and
39:33this is where we cut the appliance.
39:37We cut it from the C to the C on the
39:39other side.
39:40Okay?
39:42Uh this is my active component and then
39:44we use the expansion screw and we we
39:48right we draw with with two lines like
39:50this.
39:51And then for the retention,
39:54I can use Adams on the upper left 6.7 mm
39:59stainless steel wire, double Adam on the
40:01other side of 0.7 mm stainless steel
40:04wire and because the uh my active
40:08component is an expansion screw, the
40:10advantage is that on the active unit, I
40:12can add retentive components. It does
40:14not interfere with the tooth movement.
40:16So, I can use South end
40:18on both central incisors as an anterior
40:22retentive component. South end is 0.7 mm
40:25stainless steel wire.
40:27And of course, because the teeth are in
40:29crossbite and the movement of teeth will
40:31be uh
40:33uh
40:34interfered with the occlusion, it's
40:36important to go for a posterior bite
40:37plane.
40:40So, this is generally speaking posterior
40:42bite plane, anterior expansion screw,
40:44and I give the patient instructions to
40:45open it once or twice a week. Uh and
40:48this is how the blocks of teeth will
40:51move. And this is how the South end is
40:53not really preventing its movement.
40:55Okay? And let's see again. So, the
40:57patient is expanding it, and the South
41:00end is not preventing it because the
41:01acrylic is being cut here.
41:04And the whole unit, the whole this piece
41:06of the acrylic, the whole thing is
41:08moving
41:09laterally.
41:12So, this is the patient before and
41:13after. Another case is a closure of
41:15diastema.
41:17And another name for the um
41:20type of anchorage that is presented is
41:23the reciprocal anchorage.
41:25Okay, so this is a patient with big
41:27diastema. The child is being disturbed
41:30aesthetically with this diastema.
41:33Um then I need to think about
41:35uh
41:37closure of this diastema. So, can I do
41:39this with simple tipping movement? As
41:42long as the incisors are mesially
41:45inclined or upright, then it's possible
41:48to tip both of them toward each other.
41:51But, if the incisors are mesially
41:53tipped, I cannot do this. Okay? For this
41:56patient, luckily, it's possible to go
41:58for
41:59uh simple tipping movement.
42:01So, the first thing I need to think
42:03about is what active component can
42:06move these central incisors within the
42:09line of the arch mesially.
42:11Now, the only active component that can
42:13do this is the palatal finger spring.
42:15So, I'll have a palatal finger spring on
42:17the upper right central and another
42:18palatal finger spring on the upper left
42:20central of 0.5 mm stainless steel wire.
42:24And then, I can decide on the rest of
42:26them of the active components.
42:29Um
42:30Adams clasp on the sixes of 0.7 mm
42:33stainless steel wire. Adams clasp on the
42:35D's of 0.6 mm stainless steel wire.
42:39Or, I can use
42:42uh
42:43I I I don't have to use both
42:46Adams on the D's. I can use it on one
42:47side. Uh
42:49it will be enough because I'll have
42:51three points of retention as long as the
42:53undercut is adequate for retention on
42:55the D's.
42:56Uh because the CDO smaller usually have
42:58poor undercuts and the retention um
43:02really uh is not that adequate.
43:05It's not that good.
43:07Right. So, is moving the incisors
43:10mesially interferes with the occlusion?
43:13No, it does not interfere with
43:14occlusion. So, I don't need to add
43:16posterior bite plane. I don't need to
43:18add posterior bite plane, okay?
43:20I I can use alternatively instead of
43:23having Adams on the
43:26D's, if the undercut is not adequate, I
43:29can have labial bow from three to three
43:31as an alternative, okay?
43:34Uh
43:350.7 mm stainless steel wire.
43:37Is it possible to go for a labial bow if
43:40the incisors are having palatal finger
43:42springs? Yes, because the labial bow
43:44will not interfere with the type of
43:47tooth movement.
43:49Uh that is mesial movement of the
43:50incisors.
43:53So, this is just to remind you with the
43:55active components. This is how the
43:56palatal finger spring will show after
43:58the patient fits the appliance. Only the
44:00active arm will be uh
44:03visible. The rest of the component will
44:05be hidden inside the acrylic. Okay? So,
44:08this is two uh uh glacial finger spring
44:11with uh labial bow, so it doesn't
44:13interfere with the uh retention over the
44:16tooth movement.
44:18Another case is the unilateral crossbite
44:20with mandibular displacement. Unilateral
44:23buckle crossbite with mandibular
44:25displacement. So, this is a patient with
44:27a crossbite on the left side. You can
44:29see the mandibular displacement in the
44:31facial asymmetry.
44:34And the patient is in the mixed
44:36dentition. So, the appliance of choice
44:39to correct this
44:41uh problem is to have a midline
44:43expansion screw to push the teeth across
44:46the bite.
44:47Now, the problem is not on the left side
44:50only. It's on the left side and the
44:52right side, but what happens is that
44:54as the maxilla is narrow, symmetrically
44:57narrow, the mandible will be confused
44:59where to bite, and eventually it will
45:01choose one side, and we will have
45:03mandibular displacement to avoid
45:04premature contact.
45:06So, if there is no mandibular
45:08displacement, then the problem is only
45:11on one side. Okay? And the design of the
45:13appliance should be different. But for
45:15this patient, we have mandibular
45:16displacement, then we have to go for a
45:20midline expansion screw where the
45:21acrylic is cut exactly in the middle.
45:24So, we have a midline expansion screw.
45:26We have four points of retention. We
45:28have posterior bite plane. And as the
45:30patient activates the appliance, the
45:32maxilla will be expanded.
45:34So, again, if the patient has only
45:38a crossbite, no mandibular displacement,
45:40for example, on the left side, then the
45:42cut of the acrylic should be closer to
45:44the problem. The cut should be here,
45:47not in the midline.
45:49And the acrylic should extend
45:51to include all teeth so that I will have
45:53a small active unit and a huge anchorage
45:58unit to resist unwanted tooth movement
46:00because I want only this segment to move
46:03buccally. I want the other segment to
46:05stay still. Okay?
46:07Uh this is as I said, in case I have
46:10unilateral crossbite without mandibular
46:13displacement.
46:14But if I have mandibular displacement,
46:17then the appeal should be cut in the
46:18middle. I should have a midline
46:20expansion screw right in the middle, and
46:23I'm going to push both buckle segments
46:25buccally.
46:26And this is what we call reciprocal
46:28anchorage. So um this action
46:32buckle pushing of teeth, and this is the
46:34reaction of and both of them are
46:36desirable. The I don't need to resist
46:38unwanted tooth movement. I don't need to
46:40resist this, so this is called
46:42reciprocal anchorage.
46:44If I have a single posterior tooth in
46:46crossbite,
46:48then I can use a removable appliances.
46:50For example, here
46:52uh for this patient, I just want you to
46:54focus on the crossbite on the upper
46:56right five and the crossbite on the
46:58upper
46:59uh right lateral incisor.
47:01The first question is, is it possible to
47:04correct this with simple tipping
47:06movement? Yes, it's not that severe. The
47:09lateral the orientation of the lateral
47:10allows further proclination and pushing
47:13across the bite. For the lateral
47:15incisor, what's the active component?
47:17It's a Z spring of 0.5 mm stainless
47:20steel wire. For the five, for the second
47:22premolar, I choose T spring of 0.5 mm
47:26stainless steel wire.
47:29For the retention, I can uh clasp the uh
47:33sevens
47:34uh using Adams clasp of 0.7 mm stainless
47:38steel wire.
47:39On the left side, I chose seven because
47:41six happened to be extracted.
47:44So I need to make sure that the
47:45technician knows that this is a seven,
47:47and we need we need to clasp it.
47:49On the right side, why didn't I clasp
47:52the six? I went all the way back to the
47:54seven. Well, because I'm trying to push
47:57the five across the bite.
48:00And a T-spring there with an Adams at
48:02the same time are crossing the contact
48:05with the the contact point between the
48:07five and the six is a crowd. Okay, it
48:09can prevent tooth movement. So, I have
48:12to make sure that there isn't other
48:14components that may prevent tooth
48:16movement. So, a T-spring here is enough.
48:18And since the seven is fully erupted, I
48:20can use it for retention.
48:24Um this these are only points of
48:26retention. I need a third point and the
48:28third point is Adams on the four on the
48:32um
48:33on the left side. Why not on the right
48:35side? Again, because it will interfere
48:37with the movement of the five. Okay,
48:38these are my three points of retention.
48:40And because the movement of tooth will
48:42be interfered with occlusion, I need to
48:45separate the occlusion. Why didn't I use
48:48anterior bite plane? Because the
48:50patient's overbite is
48:52average and because the patient is an
48:56adult, as you can see, the seven is
48:57fully erupted. That's it. The patient is
48:59not growing. She's an adult.
49:02The alternative is to have T-spring
49:05uh on the lateral, T-spring on the five.
49:10And instead of having Adams on the four,
49:12we can lay we can have labial bow. But
49:14again, as I said,
49:16uh the patients really appreciate it if
49:18the appliance inside their mouth doesn't
49:21show. So, you can avoid anterior
49:23component if possible. But if it's the
49:26only source of retention, then of course
49:28I have to use them. I have to use them.
49:31So, I can use labial bow three to three.
49:33An alternative is to use So, this is a
49:36third alternative, as you can see. The
49:38active components should be chosen
49:40correctly, and then the retentive
49:42components can be we can have
49:43alternatives according to the case.
49:46Here, a third option is to have South
49:48end on the upper left two and one.
49:51Upper left two and one. So, this will
49:54not interfere with the movement of the
49:55upper right two. So, a 0.5 mm can be
49:59used 0.7 mm stainless steel wire.
50:02Posterior bite plane is used because
50:05the movement is interfered by the
50:07occlusion. So, this is a Z spring
50:10and the Z spring
50:12just for you to see the design.
50:15So, this is the patient before
50:17the treatment and this is the patient
50:19after correction of the crossbite.
50:23Distalization of the buccal segment an
50:25example
50:27of using expansion screws to distalize
50:29the buccal segment.
50:32So, this is a bit
50:34this is a little bit complicated case,
50:37but it's a good idea to look at
50:38different aspects. Of course, ideally we
50:41would the treat this patient using fixed
50:43appliances, but let's say let's assume
50:46that the patient said I cannot afford
50:48for example
50:50a fixed appliance. And let's assume for
50:53the sake of the exercise that we want to
50:55correct this using
50:56simple
50:58tipping movement and removable
50:59appliances.
51:01So, the first problem is that I have
51:03both lateral incisors are in crossbite.
51:06I have lack of space and crowded upper
51:09left five and I want to correct this,
51:11okay? So, what active components can can
51:15be used? For the lateral incisors, I can
51:17use Z spring on the upper right 0.5 mm
51:21stainless steel wire and another Z
51:22spring on the upper left because these
51:24are not two adjacent anterior teeth,
51:26they are separate. Okay, so I cannot use
51:28a whole long
51:31Z spring for both of them. I have to use
51:33a Z spring for the left side and another
51:36one for the right side.
51:38So, what about the
51:40buccal segment and lack of space? Well,
51:42I can use an appliance that would
51:45distalize the buccal segment on the left
51:48side, and this can be achieved by
51:50expansion screw.
51:51What about palatal finger spring? Well,
51:53I I don't have a single tooth. I have
51:56two big molars, so it's like a block of
51:59teeth. Two big molars, multi-rooted.
52:02So, I need heavy
52:04force. So, a palatal finger spring will
52:06not be enough. Will not give a
52:08successful result.
52:10Um
52:12So, this is uh the lab form.
52:15I choose these spring on both lateral
52:17incisors separately, of course.
52:19Uh and I distalize the buccal segment by
52:22cutting the acrylic here
52:24and adding my expansion screw there.
52:27And now, since I decided on my uh
52:32active components, I need to design the
52:34retentive components.
52:36Now, Adams clasp on the upper left seven
52:39is is of course an option because, as I
52:42said, an expansion screw does not
52:45uh prevent us from using retentive
52:48components on the active unit. So, I'm
52:51cutting the acrylic here. I'm using
52:53expansion screw here, but still I can
52:55use Adams on the seven. It's difficult
52:57to use Adams on the six because the
53:00uh arrowhead and the retentive arm comes
53:03in the same exact place where the
53:06acrylic is cut. So, we will have weak
53:08area of acrylic, and it might fracture.
53:11So, the seven is a better option as long
53:13as it's fully erupted and we have
53:15undercut.
53:17Uh we can use C clasp on the upper left
53:19uh
53:20canine.
53:22On the right side, I use um Adams on the
53:25six of 0.7 mm stainless steel wire
53:28and Adams on the four of 0.5 uh sorry,
53:310.6 mm stainless steel wire. So, these
53:33are four points of retention.
53:36Four points of retention, of course,
53:37because my movement will be interfered
53:41with occlusion uh by correcting this
53:43crossbite and moving these teeth
53:46distally, I have to use posterior bite
53:48plane. Not anterior bite plane because
53:51the overbite is average. Actually, it's
53:53reduced. For this patient, it's reduced,
53:55so I cannot use anterior bite plane.
53:58So, this spring
54:00uh expansion screw
54:02uh retentive components on the seven on
54:05the left side 0.7 mm stainless steel
54:07wire on the right side on the 6.7 mm
54:10stainless steel stainless steel wire
54:12um
54:13uh C clasp as you can see, there is a
54:15little bit of space between the three
54:17and the four, so I can use C clasp on
54:19the 3.7 mm stainless steel wire
54:22and uh Adams on the
54:25um
54:28uh upper left four
54:300.6 mm stainless steel wire.
54:32Can I use south end? Well, this is a
54:35little bit tricky because it will
54:36interfere with the tooth movement. If
54:39you use south end here, it will
54:41interfere with the tooth movement of the
54:43lateral incisors as they are being
54:45corrected.
54:47Posterior bite plane to disclude the
54:49teeth is a must.
54:51So,
54:52uh the second stage, once you open the
54:54space, so let's say that the appliance
54:55was a success and you opened the space
54:58for the five, then the second stage of
55:01the removable appliance is to push the
55:04five across the bite and correct the
55:06crossbite there. So, you can use these
55:08spring
55:09and we can use Adams on the seven again
55:12so that you don't interfere with the
55:14tooth movement, Adams on the on the six
55:16on the other side for retention, and
55:19labial bow
55:20uh for anterior retention because you
55:22already corrected the anterior
55:23crossbite, you can use you can use a
55:26labial bow. Uh
55:28of course, alternatively, now don't use
55:31labial bow and use Adams on the four.
55:33This is an alternative design.
55:36And of course, the
55:38uh bite plane is a must to uh to uh
55:42disocclude the teeth and allow tooth
55:44movement.
55:46Uh this is the alternative. As I said,
55:48we can use Adams on the four instead of
55:51a labial bow. And really, the patient
55:52will appreciate it from an aesthetic
55:54point of view.
55:56So, this is a um expansion screw to
55:59distalize the buccal segment. Again,
56:01this is after expansion. So, this is
56:03distalization of the buccal segment.
56:06Uh T springs on both lateral incisors
56:09because they are
56:10uh
56:11separate. And we have the T spring on
56:13the five. So, just to remind you of the
56:15design of the active components.
56:18Other commonly used removable appliances
56:20is the one that we already talked about.
56:23A removable appliance that can help
56:25attachment to extraoral appliances. We
56:29call this Inman's appliance.
56:32Inman's appliance. Inman's appliance
56:34means a removable appliance plus
56:37facebow. This is a facebow.
56:41So, this piece of wire will connect
56:43help the patient to connect the headgear
56:46extraoral appliance, the headgear
56:47intraorally. Okay? So, a removable
56:50appliance incorporated with a facebow is
56:52called Inman's appliance, and it is used
56:55to transfer forces extraorally to the
56:57intraoral components. And usually, it is
56:59used to distalize the buccal segment.
57:04All right. Um if expansion is required
57:07at the same time, then we can use
57:10something called coffin spring.
57:12So, this is a coffin spring, and this is
57:14the active component. This is an
57:16expansion
57:17uh spring. Uh it's a heavy wire. The
57:21acrylic is cut in the middle. We
57:23activate it like this. So, we activate
57:25the appliance. We push both parts apart
57:28with using our hands, and then we fit
57:30the appliance inside the patient's
57:31mouth, and it's supposed to go to
57:33produce uh expansion.
57:36Uh and then if you add the if you add
57:38the face bow, then it is coffin spring
57:40and in mass appliance at the same time.
57:44Nance appliance is an appliance that is
57:47used to
57:48uh aid uh
57:51the distalization of the upper
57:54uh molars.
57:55Uh
57:56and it's not used alone. It should be
57:58used with a headgear. So, what happens
58:00is that the headgear produce the active
58:03distal movement of the molars
58:06and the Nance appliance is used to
58:07maintain and prevent relapse during the
58:10day because the patient cannot wear his
58:12headgear full-time. Usually he wears it
58:1414 ti- 14 hours out of the 24 hours.
58:18Now,
58:19uh the Nance should be worn full-time
58:21and it is
58:24uh used, as I said, to maintain the
58:25progress that the patient had with his
58:28headgear.
58:30The main active components are little
58:33finger springs. Uh if you're distalizing
58:36both, we use the little finger springs
58:38on both of them.
58:39And it is made of 0.5 mm stainless steel
58:41wire or 0.6
58:44uh because again, this is not a real
58:46active component. It's just to maintain
58:49to prevent relapse, okay? Because if you
58:53activate if you use it use a heavy wire
58:55and activate the distal
58:57the the little finger spring,
59:00the action is to distalize the molars,
59:02right? The reaction is to push all these
59:05teeth
59:06anteriorly. So, you will lose anchorage
59:08and the patient will end up having an
59:10increased overjet.
59:12So, you need to let the headgear do the
59:14job and then just the little finger
59:16springs to maintain the progress and
59:19prevent relapse.
59:22So, you can use the little finger spring
59:24on the molars to achieve this aim. And
59:28the rest of the components are mainly
59:29just retentive components. You can use
59:31Adams.
59:33You can use self ends. It depends on the
59:35case.
59:35And of course, the the sixes are usually
59:38having a band, and the band usually has
59:41a special tube for the headgear.
59:43So, six is having a band with a with a
59:45headgear tubes. The patient should use
59:46the headgear um evening and night time,
59:50and nudger should be used full time.
59:54The palatal finger spring should be
59:56lightly activated 1 to 2 mm, 0.5 or 0.6
59:59mm mm stainless steel wire.
1:00:04Uh an example of the use of nudger. So,
1:00:07this is my patient, 12 years of age, a
1:00:10classical Class II division 2
1:00:12malocclusion. Uh you can see the molars
1:00:15fully in a Class II,
1:00:17quarter unit Class II, and very, very
1:00:20deep overbite.
1:00:21So, my aim is to use headgear to
1:00:24distalize the molars.
1:00:26So, we used nudger appliance.
1:00:29As you can see, there is a band on the
1:00:30six, and a band on the other six, and
1:00:32then I have palatal finger springs on
1:00:34both sides,
1:00:35slightly activated to allow
1:00:39uh prevention of relapse. Okay? The rest
1:00:41of the components are for retention.
1:00:45And you can see that we used flat
1:00:48anterior bite plane at the same time to
1:00:51modify the appliance and reduce the
1:00:53overbite as well.
1:00:56So, if you look at the molars,
1:00:59they are over corrected on both sides.
1:01:00They're almost Class III,
1:01:02and who's doing the job by distalizing
1:01:05the buccal segment is not the removable
1:01:07appliance. It's the headgear that the
1:01:08patient is wearing evening and night
1:01:10time only.
1:01:11So, this is to continue treatment. We we
1:01:13fitted fixed appliances,
1:01:15and this is the molar relationship a
1:01:17little bit over corrected, quarter unit
1:01:19Class III on both sides.
1:01:22And this is the patient before and
1:01:24after.
1:01:25So, just to show you how we use natural
1:01:28appliance in
1:01:31to correct a certain type of
1:01:32malocclusion.
1:01:34Uh thank you for listening.

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