RMS

1. Prepared by
Dr.Ali Mohammed alsayani
Alignment and leveling
Supervised by
Dr.Ahmad Altarawneh
Dr.Raed Alrbtah

2. Outline of the lecture
• Definition of alignment and leveling
• Goals of the first stage of treatment
• Ideal Properties for initial alignment
• Wire used in alignment and leveling
• Anchorage control in alignment and leveling
• Several important consequences for orthodontic
mechanotherapy
• Alignment of Symmetric Crowding
• Alignment in Premolar Extraction Situations
• Alignment in Non extraction Situations
• Cross bite correction
• Impacted or Unerupted Teeth
• Diastema Closure
• Leveling

3. Alignment
• Definition:-
The arrangement of the teeth in relation to their
supporting bone or alveolar process, adjacent teeth,
and opposing dentition.

4. leveling
• Definition:-
Is the process in which the incisal edges of the
anterior teeth and the buccal cusps of the posterior
teeth are placed on the same horizontal level.

5. • Bring the teeth into alignment.
• Control the anteroposterior position of incisors.
• Control width and the form of the dental arches.
Goals of the first stage of treatment
•Correct vertical discrepancies by leveling out the arches by:-
I. Elongation of posterior teeth.
II. Intrusion of incisors.
III. Combination of the two.

6. Ideal Properties for initial alignment arch wire
• Excellent strength and springiness.
• Long range of action.
• Low stiffness.
• Good formability.
• Ideal shape memory.
• Ideal super elasticity.
• low friction.
• Good esthetic.

7. Wires used in alignment and leveling
• Australian stainless steel wires.
• Titanium alloys:-
 Nickle titanium alloy
 Copper Nickle Titanium alloy
• Coaxial wires.
• Braided / Twisted wires.
• Composite plastics/optical glass.

8. Australian stainless steel wires
• Advantages:-
 high resiliency.
 Low coast.
 Resist corrosion.
 Good formability.
 Can be soldered and welded.
 Disadvantages :-
 High stiffness.
 Low springiness.
 High modulus of elasticity.
 Uses :-
 Mild crowding cases.
 Displaced teeth.

9. • Special plus is the best one we can used in
alignment and leveling.
It comes in different resiliencies:-
1. Regular with white label
2. Regular plus with green label
3. Special grade with black label
4. Special plus with orange label
5. Premium with blue label
6. Premium plus with blue label
7. Supreme with lavender label

10. Titanium alloy wire
 Nickle Titanium alloy (45%Ti, 53%Ni, 2%Co)
 Martinsitic stabilized alloy
e.g Nitinol was invented in 1960.
 Austenitic active alloy (superelastic)
e.g Sentalloy/ Chinese NiTi (Brustone)
 Martinsitic active alloy (thermodynamic)
e.g Neo-sentalloy
 Advantages:-
 High springiness.
 Light constant force.
 Low stiffness.
 High shape memory.
 High elastic limit.

11. Copper Nickle –titanium alloy
 Advantages :-
• The addition of copper to nickel titanium alloys
increases strength, reduces hysteresis, control
transition temperature range, reduces friction
and modified shape memory.
• Reduce patient discomfort.
• Reduce potential for root resorption.
 Uses :-
• Allow engagement of severely malposed teeth.
• Ideally for periodontal compromised cases.

12. Coaxial wires
• Combining of two or more strands of a small stainless
steel.
• Advantages:-
 Can withstand the load so they are able and used for
aligning archwires.
 Low friction.
 Low cost.
 Flexible.

13. Braided/ Twisted wires
• Very small diameter S.S wire can be braided or twisted
together by the manufacturer to form wires.
 Advantages :-
• Very flexible.
• Delivers extremely light forces.
• Full engagement of the arch wire at an early stage.
• Available in round and rectangular shapes .
• Low cost.

14. Composite plastics/optical glass
 Optiflex is a composite structure formed by top
coating optical glass fibers.
 Advantages:-
Esthetic .
Stain resistance.
provide light continues forces for initial alignment.
Very flexible.
Can be used with any bracket system.

15. SIZE OF THE WIRES
• Changing the diameter/ length of a wire greatly
affects its properties for initial aligning and leveling.
• When the diameter of wire is doubled:
1. The strength increases by 8 times.
2. The springiness decreases by 16 times.
3. Range decrease by half.
• When the length of the wire is increased:
1. The strength decreased by 2 times.
2. The springiness increased by 8 times.
3. Range increased by 4 times.

16. Anchorage control in alignment and
leveling
• BENNET and MC LAUGHLIN emphases the
need to consider anchorage in all the three
plane of space.
1. Horizontal plane.
2. Vertical plane.
3. Transverse plane.

17.  Horizontal anchorage
• Anchorage control means limiting the mesial
movement of the posterior segments while
encouraging distal movement of the anterior
segments.
• When the posterior mesialize and the anterior
procline, anchorage is being lost in the
horizontal plane.

18. BEND BACKS
• Bending the arch wire immediately behind the
most distally banded posterior tooth is called
cinching.
• It minimize forward tipping of incisors.

19. Vertical anchorage
• Vertical anchorage control involve the
limitation of the vertical skeletal and dental
development in the posterior segments and
the limitation of the vertical eruption of (or)
even intrusion of the anterior segments.

20. Transverse (Lateral) anchorage
• Control It comprises maintenance of
expansion procedure, primarily in the upper
arch, and the avoidance of tipping (or)
extrusion of posterior teeth during expansion.

21. Roller coaster effect
• Elastic force were greater than the leveling force
of the arch wire, there was tendency for anterior
teeth to tip and rotate distally, and increasing
the curve of spee, deepening the bite.

22. Several important consequences for orthodontic
mechanotherapy :
• Initial archwires for alignment should provide light,
continuous force to produce the most efficient
tipping tooth movement.
• To bring teeth into alignment, a combination of
labiolingual and mesiodistal tipping guided by an
arch wire is needed, but root movement usually is
not.
• Round arch wires should be used while rectangular
archwires should be avoided.

23. • The archwires should be able to move freely within
the brackets, at least 2 mil clearance between the
arch wire and the bracket is needed.
• The largest initial arch wire that should be used with
an 18-slot edgewise bracket is 16 mil, and 14 mil and
With the 22-slot bracket, a 16mil or 18mil.
• If only one tooth is crowded out of line a rigid wire is
needed and an auxiliary wire should be used to reach
the malaligned tooth.

24. Key points during alignment and leveling
• Forces should be kept as light as possible.
• Sagittal, vertical and lateral anchorage need
should be identified for each case.
• Lacebacks and bend backs to be used in the
initial stages to avoid unwanted tooth
movement.
• Posterior segment should be supported with
headgears / TPA in maximum anchorage cases.

25. Alignment of Symmetric Crowding
• The flat load-deflection curve of superelastic
NiTi makes it ideal for initial alignment when
the degree of crowding is similar on the two
sides of the arch.

26. • The extreme springiness of superelastic wires
is not a totally unmixed blessing. When these
wires are tied into a malocclusion, they have a
tendency to "travel" around the arch as the
patient chews, especially if function is mostly
on one side.

27. To open space for teeth that crowded out
of arch there are two ways
• Use crimped stop on the wire just in front of molar
tube

28.  Use of coil spring to open space
 Use of open coil spring in the anterior or posterior
segments to create space for blocked out teeth .
 Open coil springs should not be used until 0. 018 or 0.020
round wires are in place.

29. Alignment in Premolar Extraction Situations
• In patients with severe crowding of anterior
teeth, it is necessary to retract the canines
into premolar extraction sites to gain enough
space to align the incisors.
• If maximum anchorage is needed (we but
bone screw on the alveolus).

30. • In less extreme but still sever crowding(coil spring
from the first molar to tip canine distally).
• When this is done, the arch wire preformed to have
an exaggerated reverse curve of spee, to limit
forward tipping of the molars.

31. Use of laceback in extraction cases:
• To control mesial movement of the canines during
alignment and leveling, This prevents incisor
extrusion during these stages of treatment.
• To retract canines in cases with labial segment
crowding during alignment and leveling.

32. • protection of flexible archwires in extraction
spaces.
• centerline correction by unilateral canine
retraction in one or both arches.

33. Alignment in Nonextraction Situations
• Alignment in nonextraction cases requires increasing
arch length, moving the incisors further from the
molars.
• In this circumstance, just tying a superelastic wire
into the bracket slots is ineffective.
• Use crimp a stop on the wire at the molar tube (this
type of arch expansion has the potential to carry the
incisors facially).
• An alternative is to bypass the brackets on teeth that
are crowded lingually.

34. Cross bite correction
• Individual teeth displaced Into anterior cross bite.
• Correction of the cross bite requires first opening
enough space, then bringing the displaced tooth or
teeth across the occlusion into proper position.

35. • Occlusal interferences can make this difficult,
the patient may tend to bite brackets off the
displaced teeth.
• It may be necessary to use a bite plate
temporarily to separate the posterior teeth
and create the vertical space needed to allow
the teeth to move.

36. Correction of Dental Posterior Cross bite
1) Heavy labial expansion arch.

37. 2) An expansion palatal arch.

38. 3) Cross elastics.

39. Transverse Maxillary Expansion by
Opening the Midpalatal Suture
• It is relatively easy to widen the maxilla by opening the
Midpalatal suture before and during adolescence, but
this becomes progressively more difficult as patients
become older.
• Separation of the suture should be the first step in
treatment, before either extraction or alignment.

40. Impacted or Unerupted Teeth
• Bringing an impacted or unerupted tooth into
the arch creates a set of special problems
during alignment.
• The most frequent impaction is a maxillary
canine or canines, but it is occasionally
necessary to bring other unerupted teeth into
the arch.

41. The problems in dealing with an unerupted
tooth fall into three categories
(1) surgical exposure.
(2) attachment to the tooth.
(3) orthodontic mechanics to bring the tooth
into the arch.

42. Surgical Procedures
• Two basic types:-
1. Closed method.
2. Open method.
• According to Johnston, Gaulis & Joho:-
For labially impacted tooth: Closed method
indicated .
For palatally impacted tooth : Open method is
indicated .

43. Method of attachment
1. Lasso technique.
2. Threaded posts.

44. 3. Bonded brackets/ button.

45. Mode of Traction
1. Ligature wire.
2. Elastomeric chain.

46. 3. K9 spring.
4. Elastic thread.

47. Diastema Closure
• A maxillary midline diastema is often
complicated by the insertion of the labial frenum
into a notch in the alveolar bone.
• It is better to align the teeth before frenectomy.

48. Leveling
• leveling can be accomplished with continuous
archwires, simply by placing an exaggerated curve
of Spee in the maxillary archwire and a reverse
curve of Spee in the mandibular archwire.

49. Deep Overbite
• Deep overbite can be divided into two types.
1. True deep bite:-
which is mostly due to the infra eruption of
posterior teeth.
2. Pseudo deep bite:-
Is due to the supra eruption of anterior teeth.

50.  Advantages:-
• A long range of action.
• Constant direction of action.
• More easily estimated biomechanical effects.
• Ability to use wires in the same arch.
• Avoidance of some unwanted effects of reciprocal
forces.
• Avoidance of frictional forces.
 Disadvantages:-
• Complexity of wire fabrication.
• Poorer control of overall arch form.
• Less ‘fail-safe’ effect.
Segmented archwire

51.  Advantages:-
• More rapid relative incisor intrusion.
• Range of action of the archwire.
• Slightly greater incisor intrusion.
 Disadvantages :-
• Left active until over-correction of the overbite.
• Greater relative extrusion of the canines.
• Second arch leveling phase may be required.
Sectional archwire

52. Auxiliary archwire mechanics
 Indications:-
• When the incisors are upright, the canines
distally angulated.
• The combination of a deep overbite and
gingivally placed canines.
• A very gummy smile cases.

53. Rocking chair Ni-Ti wires
 Advantages/indications :-
• Non-extraction arches .
• Earlier engagement of brackets with a rectangular wire.
• Long range of action.
• Anterior open bites cases.
 Disadvantages:-
• Can cause molar rotation and premolar expansion.
• Can causes incisor proclination.
• Lingual crown torque cannot be placed in the wire.
• Asymmetric bite opening sometimes occurs.

54. Treatment of deep over bite
• Extrusion or Uprighting of posterior teeth.
• Increasing the inclination of upper and lower
anteriors.
• True intrusion of upper and lower anteriors.
• Combination of two or more of the above
procedures.

55. Extrusion or Uprighting of posterior teeth
• Indication:-
 Patients with a horizontal growth pattern.
 Growing individuals .
 True deep overbite cases.

56. Proclination of upper and lower anteriors
• This can be done only if the soft tissue profile
permits it or in cases with retroclined anteriors.

57. True intrusion of upper and lower anteriors
• Bite opening by true intrusion although can be
used in both grown and growing individuals, it
is effective in growing individuals.
• True intrusion of incisors is indicated in cases
of pseudo deep bite where the incisors are
supra erupted.
• Methods:-
– Utility arches.
– Burstone Intrusion arches.
– Three piece intrusive arch.

58. Utility Arches
• It is a complete arch extending across both
buccal segments, the utility arch engages only
the two molars and four incisors.
• It is commonly known as 2 x 4 appliance (Two
by Four appliance).

59. Types of utility arch
1. Passive utility arch
2. Intrusion utility arch
3. Retrusion utility arch
4. Protrusion utility arch
Passive utility arch can be used for stabilization
(or) as a space maintainer It is ideal in the mixed
dentition as it permits the eruption of canine
and premolars.

60. Burstone Intrusion arches
• Originally proposed by Burstone, these springs are
made of 0.017” x 0.025” TMA wire.
• The upper and lower arches have to be leveled and
aligned and a rigid stainless steel wire, preferably of
0.017” x 0.025” dimension should be engaged.
• The anchor molars are reinforced with a TPA in the
upper and a lingual holding arch in the lower arch.

61. Three piece intrusive arch
It consists of the following parts:-
• The posterior anchorage unit.
• The anterior segment with posterior extension.
• Intrusion cantilevers.

62. References
• Contemporary Orthodontic 5th edition – William R. Proffit.
• Excellence in orthodontic 2010 – David Birnie, Nigel Harradine.
• Cobb NW III, Kula KS, Phillips C, Proffit WR. Efficiency of multistrand steel, superelastic NiTi
and ion-implanted NiTi arch wires for initial alignment. Clin Orthod Res 1:12-19, 1998.
• Isaacson RJ, Lindauer SJ, Rubenstein LK. Activating a 2 × 4 appliance. Angle Orthod 63:17-24,
1993.
• Scheffler NR. Patient and provider perceptions of skeletal anchorage in orthodontics. MS
Thesis, University of North Carolina, 2005.
• Gunduz E, Schneider-Del Savio T, Kucher G, Schneider B, Banteleon HP. Acceptance rate of
palatal implants: A questionnaire study. Am J Orthod Dentofac Orthop 126:623-626, 2004.
• Cobb NW III, Kula KS, Phillips C, Proffit WR. Efficiency of multistrand steel, superelastic NiTi
and ion-implanted NiTi arch wires for initial alignment. Clin Orthod Res 1:12-19, 1998.
• Localizing ectopic maxillary canines-horizontal or vertical parallax? Eur J Orthod 25:585-589,
2003.
• Sandler JP. An attractive solution to unerupted teeth. Am J Orthod Dentofac Orthop 100:489-
493, 1991.
• Vardimon AD, Graber TM, Drescher D, Bourauel C. Rare earth magnets and impaction. Am J
Orthod Dentofac Orthop 100:494-512, 1991.
• Silleul MP, Jordan L. Torsional properties of NiTi and Cu-NiTi wires: The effect of temperature
on physical properties. Eur J Orthod 19:637-646, 1997.

63. Thank you