Finishing and detailing in orthodontics /certified fixed orthodontic courses by Indian dental academy

Finishing and detailing

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Introduction
Finishing and detailing , which is the last
stage in treatment, it is important to
continue focus on the treatment goals.
They are
Condyles in a seated position – in centric
relation.
Relaxed healthy musculature.
Andrews Six keys.

Ideal functional movements – a mutually
protected occlusion.
Periodontal health
Best possible esthetics.


Dougherty – 1976. outlined 17 factors to be
considered in finishing and detailing.
Correction and Overcorrection of the A-P Jaw
Relationship
The tip and torque - anterior brackets –
demand for anchorage, - upper arch,
total anchorage - anteroposterior correction
is about the same for all appliances.
Overcorrection of the Class II case is the greatest
challenge in this area.


Establishing Correct Tip of the Upper and

Lower Anterior Teeth
Tip in face- eliminates the need for 2nd-order
bends - treatment more efficient.
Wire bending reqiured when:
improper bracket placement relative to the
vertical reference lines of the anterior teeth
irregularly shaped anterior teeth -peg-shape LI present.


Establishing Correct Torque of the Upper and

Lower Anterior Teeth
The anterior torquing needs of patients vary - no single
set of bracket torque values can meet the needs of all
the cases .
Adjust the torque in the upper and lower anterior
segments - various stages of treatment .
Eg. overjet correction of the moderate-to-severe Class
II case


torque is frequently lost in the upper anterior
segment
 lower incisors are angulated forward
compensate by adding lingual root torque to the
upper anterior teeth and
labial root torque to the lower anteriors


Coordinating Arch Widths and Archform
Coordination of archwires - from beginning
through the rectangular wire phase -prevent
crossbites from developing.
asymmetry cases -distorted anterior archforms,
(cuspid regions).
To correct - during the finishing stage,
• cross-elastics - cuspid areas,
• archwires canted in the direction opposite to the
asymmetry.


Cross-elastics in cuspid
areas used to
compensate for
asymmetrical upper
archform (symmetrical
arch indicated by dashed
line).
Modified upper archform
(dotted line): archwire
canted in direction
opposite to asymmetry.


Establishing Correct Posterior Crown Torque
Built in torque- preadjusted posterior brackets
-eliminates wire bending.
a tendency for upper palatal cusps to be situated
below the occlusal plane,
posterior buccal root torque - rectangular
finishing wires.
In the lower arch, 1st & 2nd molars- undesirable
lingual tipping, - buccal crown torque to the
rectangular archwires.


Establishing Marginal Ridge Relationships

and Contact Points
Proper marginal ridge relationships - finishing
stage - function of bracket height.
Incorrect bracket height - apparent early .
effective to reposition brackets as early as
possible.
An .014" round wire can be used to step any
improperly positioned brackets.


Upper central
incisor with
incorrect bracket
height and
compensating step
in .014" archwire.

Bracket
repositioned at
next appointment,
with .016"
archwire.

Correction of Midline Discrepancies
minor discrepancies -3mm or less 5 methods of elastic wear
A single Class II elastic on one side and a double
Class II elastic on the other, for cases with a
bilateral Class II component
A single Class II elastic on one side only, when
the overjet results in a slight Class II relationship
on that side and the opposite side is in a Class I
position.


Class III elastics on one side and Class II elastics on
the other, for cases with the corresponding dental
relationships.
A single Class III elastic on one side only, when
that side is in a Class III position and the opposite
side has a Class I dental relationship .
An anterior cross-elastic, when the discrepancy
occurs primarily in the anterior segments.



Establishing the Interdigitation of Teeth
rectangular wires - the teeth unable to settle .
Settling before debonding - L/.014" & U/ .014"
round sectional wire from lateral incisor to
lateral incisor + vertical triangular elastics .
Adv. - establish an individual archform.


Checking Cephalometric Objectives
Progress headfilms - halfway through treatment reassessment of anchorage & changes in the
division of treatment time.
final cephalometric headfilms- 3 or 4 months
before debonding.


Important factors to evaluate with progress and final
cephalometric x-rays include
• AP posn. of the incisors
• incisor angulations,
• changes in the occlusal plane,
• the degree to which vertical dev. - occurred or
restricted, &
• the success of the correction of horizontal and
skeletal components of the case.


Checking the Parallelism of Roots
The tip built into preadjusted brackets - proper root
paralleling.
A panoramic x-ray - before debanding to evaluate
root parallelism.
If crown-root angulation is beyond normal
standards, bracket repositioning or archwire bending
may be required to modify the root positions.

Maintaining the Closure of All Spaces
space closure be maintained - extraction cases passive tiebacks in the finishing stage.


 Evaluating Facial and Profile Esthetics
Esthetic evaluation - ongoing process during all
stages of orthodontic treatment.
A projection of esthetic goals - made as part of
the treatment plan.


Checking for TMJ Dysfunctions such as

Clicking and Locking
Document - TMJ dysfunction prior to treatment,
Monitor - TMJ dysfunction during treatment.
Problems – if managed before the development of
true internal derangement, - joint function - reestablished without permanent damage.
Monitor the patient for symptoms of TMJ
dysfunction during retention.


Checking Functional Movements
Before debonding, - checked for interferences
during protrusive movements and lateral
excursions.
lower eight most anterior teeth make contact with
the upper six most anterior teeth during protrusive
movements.
requires - slight widening of archform - bicuspid
area, - mesial of the lower bicuspids contacts the
distal of the upper cuspids.


Determining if All Habits Have Been

Corrected
Habits such as tongue thrusting - been corrected
before the finishing stage .
because as the patient grows, airway size
increases and the tongue can assume a more
posterior position.


 Correction of Rotations and Overcorrection Where

Needed
Most rotations - eliminated before finishing stage.
Any remaining rotations can be corrected during
finishing by one of three methods:
Rubber rotation wedges under the rectangular
archwire.
Steiner rotation wedges— these are useful because
they can be placed after the archwire is in position.
Lingual elastics—the most effective method.


Establishing a Relatively Flat Plane of

Occlusion
Reasons for completing cases to a relatively flat
occlusal plane, according to Andrews, proper fit of the upper dentition against the lower
dentition.


According to McLaughlin, Bennet & Trevisi,
attention should be given to the following
considerations during the finishing stages of
treatment.
Horizontal
Vertical
Transverse
Dynamic
Cephalometric & esthetic.


Horizontal Considerations
Coordination of tooth fit.
A major consideration – coordination of tooth fit in
ant. and post. areas.
Ant. & post. teeth fit well
– 20% of cases.
Crowns of upper ant. teeth do
Not occupy enough space
60% of cases.
Relative to the lower ant. teeth
Excess of upper ant. tooth substance – 20% of cases.


Mandibular excess in 60% cases will be evidenced
by
Post. space closure – difficult in upper arch –
maintaining correct overjet.
Overjet is correct, buccal segments – mild to
moderate class II.
Ant. space closure – upper arch – difficult while
maintaining the correct overjet.
Horizontal plane  difficulty relates primarily to
factors of tip in the ant. teeth, incisor torque &
tooth size.


Establishing the correct tip of the anterior &

posterior teeth.
Main factor – influence amount of space occupied by
each tooth.
Andrew’s prescription –
40° tip- upper ant. seg, 6° tip – lower ant. seg.
34° tip differential - size of upper ant. seg. & lower.
 Improved tooth fit – 60% disc. cases.
Shape of incisor crowns:
• Barrel or  shaped – tipping – little effect

 Providing adequate incisor torque
Torque control – weakness of PAE.
 Approx. 1mm seg. of wire – in a bracket
slot – same dimension – required to
carry out difficult root movement.
 Full size wires – not used, to permit
sliding.  effectiveness relative to
torque control.
 U/L torque needs vary greatly.
Additional palatal root torque – upper
incisor br.
Addnl. labial root torque – lower incisor
br.

Management of tooth size discrepancies.
Tooth size – ‘seventh key’ – normal occlusion.
Common – lack of tooth mass – u/ant. seg. relative to
l/ant. seg.
Excess tooth mass – L/ ant. seg – adv. to carry tooth
redcn. – initial stages of trt.
Controlling rotations.
In out compensation built into br. + correct br.
positioning  effective in controlling rotns.
Beneficial in class I & Cl. II cases – Pm br. 0.5 mm
to mesial  buccal cusps rotate – distally to class I,
palatal cusps – mesially – occlude accurately.

Lower canine br. – slight mesial.
Labial rotn. of mesial aspect – better contact with
distal aspect of lower laterals.

Maintaining closure of all spaces.
Passive wire tie backs – when rect wires in place,
Lacebacks – molar – cuspids – when light wires used.
In extn. cases – figure of 8 liagature ties –across extn.
site – to keep it closed.


Horizontal overcorrection.
Cl II & Cl III cases – consider overcorrection.
Fully correct the A/P position of dentition – using
elastics, head gear etc.
After correction – these methods discontinued/ worn
part time – 6-8 weeks.
If stable – appl. removed.
Relapse – horizontally overcorrected.


Vertical Considerations
Correct crown lengths, marginal ridge

relationships and contact points.
Correction – completed – rect. NiTi stage of trt.
If not done early, in finishing stage – minor
archwire bends.
Does not ensure stability.
These relns. to be corrected 1-2 yrs, before br.
removal.


Final management of the Curve of spee.
Low angle cases:
Beneficial to level the entire curve of spee.
This include banding 2nd molars.
Upper bite plate retainers – in cases showing a
tendency for bite deepening – retention.
High – angle cases:
High angle cases – with open bite tendencies – impt.
to leave some curve of Spee in back of the arch.


Vertical overcorrection – deep bite and open bite

cases:
Br. On ant. teeth – 0.5 mm more gingival – open bite.
- 0.5 mm more incisally – deep bite.
Bite opening curves – cases resistant to bite opening finishing stage.
Towards end of trt. – 1-2mm over bite,
settle to 3-4mm.
Openbite cases – impt. to evaluate – tongue position
& tongue habits.

Transverse Considerations.
Arch form.
Single arch form for every patient – efficiency in arch
form management.
Accuracy or stability – not achieved.
For balance b/w efficiency & accuracy –
3 std. Templates( square, tapered & ovoid) – to
establish arch form – early stages of trt.
Use of a wax template – compressed over br. In lower
arch, before placement of rect. SS wire.
Allowing – settle with light wire – last trt. Procedure.

Archwire Coordination.
In all wire sizes – lower arch form established.
Upper coordinated – lower wire,
3mm wider ant. & post. than the lower wire.
Post. Torque considerations – beneficial to widen
upper arch – post. Segments – 5mm.
Minor maxillary narowing – finishing stages of trt.
‘Jockey wire’. – 0.045 arch wire coordinated – upper
arch,
widened 6mm/side.
Secured to head gear tubes

Establishing posterior torque.
Progressive buccal crown torque – appliance system
– lower post. Seg.
Slight widening tendency – lower arch.
Upper molars – provided with additional buccal
root torque.
Important to have adequate width maxillary bone –
buccal roots – not compressed against the cortical
plate.


Transverse over correction.
Cases – showing narrowing – over expanded &
maintained.
Maxilla expanded – palatal cusps of upper arch
are in contact with buccal cusps of lower arch.
Palatal bar – maintain expansion – till rect. SS
wire.
Torque in post. Br. + torque in arch wire – allow
post. seg. to settle.


Dynamic Considerations
 Establishing centric relation and checking functional

movements.
Evaluate orthodontic cases – CR noted at beginning of trt.
Re-evaluate mandibular posn. as finishing stage of trt.
commences.
Patients – checked for interference – protrusive & lateral
excursions.
Protrusion – lower eight most ant. teeth – contact with upper
six most ant. teeth.
Lateral excursions – cuspid rise – slight ant. contact,
disclusion of post. teeth , working & balancing sides.

Checking for TMJ dysfunction.
Document any evidence of TMJ dysfunction prior to
trt.
Monitored during ortho trt. – if symptoms develop.
Normal TMJ fn. reestablished – if managed prior too
true int. derangement.
Seated & reasonably centred condyle position – most
beneficial posn. during ortho trt.


Cephalometric & Esthetic
Considerations
Cephalograms – taken half way through trt.to assess
– anchorage factors
- help revisions in trt. planning as trt. progress.
Final ceph. film – evaluate –
AP position of incisors.
Changes in the mandibular plane
Vertical dev.
Success in correcting horizontal, sk. & dental
components of the problem.

Settling the Case
Rect. wires restrictive for settling of teeth –
closing stages of trt.
0.014 or 0.016 round wire – lower arch
0..014 round sectional wire – LI to LI / upper.
Vertical  elastics – settling needs to occur.
Full time wear for first 2 weeks, then night wear
for next 2 weeks


Variations:
Cuspids labially displ. – extend sectional wire
in upper ant. seg – to hold them in posn.

Diastemas – areas tied lightly with elastic
thread or ligature wires.
Teeth extd. – figure of 8 ties –across extn. sites.
Palatal expansion – small removable palatal
plate – 0.018 wires extending interproximally in
the gingival areas

Moderate to severe Cl II/I,
upper full arch wire, wire bend back distally.
Settling longer than 6weeks – lower rect. wire used

Conclusion.
With the built in features of the preadjusted
appliance and the correct bracket placement,
moving teeth to their finished positions begins as
soon as the brackets have been placed and the first
archwires tied in. There is a gradual flow towards
the finishing stage with less work required at the
end.
Bennet & Mclaughlin has redefined finishing &
detailing as the correction of errors made prior to
finishing & detailing, over correction as needed
and settling of the case.

Thank you
Leader in continuing dental education


Finishing and detailing in orthodontics /certified fixed orthodontic courses by Indian dental academy

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