detailing and finishing in orthodontics

1. FINISHING AND DETAILING IN
ORTHODONTICS
BY:
DR JASMINE ARNEJA

2. CONTENTS
 Introduction
 Evolution
 Dougherty’s factors in finishing
 Factors affecting the finishing phase
 Esthetic procedures in finishing
 Periodontal procedures in finishing
 Finishing to ABO requirements
 Positioners for finishing
 Conclusion

3. Introduction
 Man has always tried to attain perfection in all his endeavours. In recent
times, great deal of emphasis is placed on achieving perfect finishing of
the orthodontic treatment so that the results are pleasing to the eye
and hopefully are more stable and conducive to an improved
function and health.

 Although, the earlier authors like Tweed did mention finishing of a case,
the impetus to this concept was given by Andrews, who expressed his
dissatisfaction with the hundreds of completed cases that he saw at
various meetings and which he felt were lacking in perfect occlusion. His
own study of 120 non-orthodontic models led him to formulate the "six
keys to normal occlusion ".
 Finishing is considered to be very difficult and time consuming in
Conventional Begg therapy. But the same has become very easy with
the PEA systems. If the tip, torque and in-out compensation built into the
appliance is accurately suited to the patients dentition, and if the
brackets are properly positioned, then only minimal wire bending should
be required to complete the treatment.

4.  Finishing : It is the last step, before active treatment is
discontinued, of ensuring that the teeth and related structures are
positioned in such a way as will lead to a better stability of results,
enhancement of esthetics, optimised functions of the stomato-
gnathic system and an improvement of the health of the
periodontium.
 Detailing : It is the achievement of the ideal positions of every
tooth in the vertical and horizontal planes with particular reference
to the individual in-out, rotation, tip and torque adjustments.

5. Evolution of the concept of finishing
The concept of finishing has changed from that of the earlier authors
who primarily relied on nature to achieve final finishing in each
individual case.
 According to Angle, "the best the orthodontist can do is to secure
normal relations of the teeth and correct the general forms of the
arch, leaving the finer adjustment to individual type form to be
worked out by nature, which must, in any event, finally triumph".
 Tweed relied primarily on placement of the lower incisors over
basal bone. He also stressed the importance of artistic (second
order) bends in the archwire.
 Begg's philosophy on finishing emphasized the routine over
movement and overcorrection of all aspects of the malocclusion
(e.g. Deep-bites were finished in edge to edge or slight open bite,
class II cases were finished in super class I, class III). So that teeth
would settle into proper positions after tissue rebound.

6.  Merrifield belief of finishing also plans stress on overcorrecting
major problems so that changes seen during denture recovery would
move occlusion towards ideal.
 According to Bench et al “The natural forces of eruption and natural
forces of occlusion combine with those of physiology and growth to
settle teeth functionally into the best position for each individual's
characteristics.”
 Andrew's in 1972 went against this belief and published six keys
to normal occlusion. This study established normal values for in
out, tip and torque for each individual tooth which were then built into
the edge wise brackets for the straight wire appliance.

7. DOUGHERTY’S FACTORS IN FINISHING
 In 1976, Dougherty described 17 factors that should be considered
in the finishing and detailing stage of orthodontic treatment.
1)Correction and overcorrection of A.P. jaw relationship
 Proffit and Rickett’s recommends over treatment of Class II and
Class III malocclusion to overcome rebound of 1-2 mm.
 Zachrisson overcorrects rotations and labiolingual displacements of
individual teeth to 1/10th overmovement.
 McLaughlin and Bennett contend that Class II case with deep bites
benefit from overcorrection to an end-to-end position, and
maintenance of that position with night time Class II elastics for six
to eight weeks, which is followed by settling into an ideal Class I
relationship.

8. 2) Establishing correct tip of upper and lower
anterior teeth.
AlOuabandi et al reposrted 6-7degree of lower
incisor flaring when simply leveling the curve of
spee
Raleigh Williams states that lower incisor apices
should be spread distally to the crowns and the
apices of the lower lateral incisor must be spread
more than those of the centrall incisor. The apex
of the lower cuspid should be positioned distal to
the crown.
According to MBT (40’ upper anterior, 6’ lower
anterior) the 34 degree of additional tip helps in
overjet maintenance and better fit

9. 3) Establishing correct torque of upper and lower anterior teeth
Torque is frequently lost during the retraction phase of treatment,
especially in class II div 1 cases. Thus anterior teeth must be torqued to
maintain the correct overjet and overbite and to establish stability

10. 4) Coordinating arch widths and archform
 Arch form coordination prevents development of a cross bite.
 McLaughlin and Bennett prefer widening the archform in the
bicuspid area, so that mesial of lower bicuspid contacts distal of
upper cuspids and therefore the lower eight most anterior teeth
make contact with upper six most anterior teeth during protrusive
movements.

11. 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.

12. 5) Establishing correct posterior crown torque and crown tip
Mclaughlin and Bennett state that correct posterior crown torque is
essential to prevent posterior interferences from developing and to
allow seating of centric cusps.
In normal situation, the lingual cusp of the mandibular posterior teeth
should be at the same level or a milimeter of the buccal cusp. This
relationship makes the occlusal table of posteriors relatively flat tereby
promoting a better contact between the maxillary lingual cusp with
maxillary fossae.
“Rolling in” is a common phenomena seen in mandibular posterior
teeth. In the maxillary arch, the palatal cusps of 1st molar and second
premolar tend to be longer than the buccal cusp, thus disturbing proper
interdigitation
Therefore flattening the CURVE OF WILSON results in improvement in
interdigitation of maxillary and mandibular teeth.

14. 6) Establishing marginal ridge relationship and contact points
 Marginal ridges are a key to achieve relative vertical positioning of
posterior teeth. This will position the cusp and fossae of adjascent
teeth at the same level. Thereby the CEJ will also be at the same
level, producing equal and suffient bone support and healthier
periodontium

15. Contact point:
 Contact surfaces of teeth are generally located in the occlusal 1/3 of the
proximal walls, slightly buccal to the central fossa in the molar and premolar
area with the exception of maxillary 1st and 2nd molars.
 The contact point between max incisors is located between the most incisal
1/3 having the perception of a vertical line
 From CI To Canines, contact points gradually move from incisal to gingival
 Contact points must be taken into good consideration to provide adequate
post treatment stability and healthy periodontium.

16. 7) Correction of midline discrepancies
It is important to establish the origin of the discrepancy in order to
correct it
Upto 3 mm of mildline discrepancy can be corrected in this phase
Usually elastics are enough for midline correction but at times
asymmetric stripping may be required

19. 8) Establishing the interdigitation of teeth
 Different authors use different configuration of elastics for final
seating of occlusion. The elastics are worn after rectangular
arches are changed to light round wires so that teeth can settle more
comfortably.
 Alexander also recommends chewing sugarless gum to get good
interdigitation of teeth.
 Proffit describes 3 ways to settle the occlusion:
◦ Replacing rectangular wires by round light wires with some
freedom of movement and using light vertical elastics
◦ Using laced posterior vertical elastics after removing the posterior
wire segments
◦ Tooth positioner

20. Laced vertical elastics

21.  Variations:
◦ Cuspids labially displ. – extend sectional wire in upper ant. seg to
hold them in postn.
◦ Diastemas – areas tied lightly with elastic thread or ligature
wires.
◦ Teeth extracted. – figure of 8 ties –across extraction. sites.
◦ Palatal expansion cases -a small removable palatal plate –
maintain expansion during settling phase
◦ Moderate to severe Cl II/I, full upper arch wire is used with wire
bend back distally- controls OJ

22. Serpentine wires:- 1 week before appliance removal U&L arch wires
are removed ,ligated together in a serpentine fashion from PM to PM
with ligature wire--- occlusion to settle without any interdental
spacing– (in minimal discrepancies of tooth position)

23. Vertical spaghetti elastics:-
1 week before appliance removal U&L arch wires are removed . 0.16” ss
wire secured in L arch with light steel ligatures and no arch wire in upper
arch.
Series of triangular elastics placed btwn two arches. 3 arms of elastic
include distal br. wing of one max tooth ,mesial br. wing of the postr tooth
and the entire br. of mand tooth closest to it. In CI region two elastics
placed in midline.
Wear full time – rapid settling of occlusion
Contraindicated in cases originally characterized by deep bite (Class II div
2) :- serpentine wires used

24.  Settling elastics with class II pull:- 2oz elastic started over L2M
&U1Molar twisted and engaged over next 2 teeth and repeated to
the UCi on X side

25.  Settling elastics with class III pull:-starts from U2&L 1 M and extends to
the Ci. on X side

26.  Box elastics
 w/m elastics

27. 9) Checking cephalometric objectives
 McLaughlin and Bennett recommend that progress headfilms
should be taken about halfway through treatment to allow time for
reassessment of anchorage and possible changes in division of
treatment time. They prefer to take final cephalogram three or four
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.iation occurred or restricted, &
◦ the success of the correction of horizontal and skeletal
components of the case.

28. 10) Checking the parallelism of roots
 A panoramic X-ray should be taken before
debonding to evaluate root parallelism.
Parallel roots provide adequate bone support around
each tooth thereby preventing tooth tipping to any side
A v bend can be created in the midline to avoid root
tipping while retraction.
In earlier treatment prescriptions, root uprighting was a
definite stage in the treatment. With the advent of sliding
mechanics and PEA, nedd for root uprighting has
diminished.
Fuller wires (0.021 x 0.025 for 0.022” slots and 0.017 x
0.025 for 0.018” slots) are preferred. In case evident root
tiping needs to be done, beta ti vires are recommended)

29. 11) Maintaining the closure of all spaces
 McLaughlin and Bennett prefer passive tiebacks in finishing
stage especially in extraction cases to maintain space closure. Also
lacebacks are routinely used.
12) Evaluating facial and profile esthetics
 Roth suggests that the tip of upper incisors should be 2-2.5mm
below the lip embrasure of the upper and lower lips and 1mm of
attached gingiva should be showing on full smile.
 Artistic positioning of the upper anterior teeth has been
recommended by Tweed, Mollenhauer and recently by Sheridan.

30. 13) Checking for TMJ dysfunctions such as clicking & locking

31. 14) Checking functional movements
 Coincidence of centric relation with centric occlusion is a goal for
various authors
 CHECK BITE!
 lower eight most anterior teeth make contact with the upper six most
anterior teeth during protrusive movements.
 Teeth should not prevent mandible from entering into or leaving any
excursion.
 In lateral excursion, the canines should provide a glide path with no
interference on the balancing side

32. 15) Determining if all habits have been corrected :
 Habits such as tongue thrusting will usually correct before finishing
stage,
16) Correction of rotations and overcorrections where needed:
 Rubber rotation wedges under rectangular wire.
 Steiner rotation wedges.
 Lingual elastics.
17) Establishing a relatively flat plane of occlusion

33. ESTHETIC PROCEDURES FOR FINISHING

34.  GOLDEN PROPORTION
 MISSING LATERALS
◦ Fixed prosthodontics is treatment of
choice
◦ In case of implants. 6.5 mm of space is
required between adjascent roots to
place a standard 3 mm wide implant
 GINGIVAL ARCHITECTURE
◦ Gingival zenith lies distal to long axis of
crown of CI and Canine and coincides
with long axis of LI

35. ADJUNCT PERIODONTAL PROCEDURE
SUPRACRESTAL FIBROTOMY

36. POSITIONERS FOR SETTLING

38. ABO- CRE GUIDELINES

39. ABO MEASURING SCALE

40.  >27

42. The buccolingual inclination of the
maxillary and mandibular posterior teeth
shall be assessed by using a flat surface
that is extended between the occlusal
surfaces of the right and left posterior
teeth. When positioned in this manner,
the straight edge should contact the
buccal cusps of contralateral mandibular
molars and premolars. The lingual
cusps should be within 1 mm of the
surface of the straight edge (fig. 9). In
the maxillary arch, the straight edge
should contact the lingual cusps of the
maxillary molars and premolars. The
buccal cusps should be within 1 mm of
the surface of the straight edge00

47. Thank you =)