1. Orthodontics
Chapter 60
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2. Chapter 60
Lesson 60.1
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3. Learning Objectives Pronounce, define, and spell the Key Terms.
Describe the environment of an orthodontic practice.
Describe the types of malocclusion.
Discuss corrective orthodontics and describe what type of treatment is involved.
List the types of diagnostic records used to assess orthodontic problems.
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4. Introduction
Orthodontics is the specialty of dentistry concerned with the supervision, guidance, and correction of the growing and mature dentofacial structure.
An orthodontist must undertake at least two additional years of formal education in an accredited university after obtaining a dental degree. To become a board-certified orthodontist, he or she must pass an examination by the American Association of Orthodontists.
In some states the expanded-function dental assistant is allowed to perform many of the tasks involved, such as sizing and placing bands and placing ligature ties and separators.
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5. Understanding Malocclusion
Malocclusion is an abnormal or malpositioned relationship of the maxillary teeth to the mandibular teeth when they are in occlusion.
Malocclusion is occlusion that deviates from a class I normal occlusion as a result of irregularities, such as those in the positions of teeth and bite relationships.
What causes or influences malocclusion?
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6. Factors Related to Malocclusion
Developmental causes
Congenitally missing teeth
Malformed teeth
Supernumerary teeth
Interference with eruption
Ectopic eruption
(Cont’d)
Interruption or absence of tooth bud formation results in congenitally missing teeth.
What are malformed teeth?
What are supernumerary teeth?
What is an ectopic eruption?
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7. Factors Related to Malocclusion
(Cont’d)
Genetic causes
Discrepancies in the size of the jaw, teeth, or both
Environmental causes
Birth injuries
Fetal molding
Trauma
Genetic: The patient usually presents with a small jaw from one parent and larger teeth from the other parent or with congenitally missing teeth.
What is fetal molding?
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8. Factors Related to Malocclusion
(Cont’d)
Habits
Tongue thrusting
Tongue-thrust swallowing
Thumb and finger sucking
Bruxism
Mouth breathing
The orthodontist corrects oral habits that cause malalignment.
Thumb and finger sucking beyond age 5 will affect facial structure development and growth.
What is bruxism?
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9. Any deviation from class I occlusion is considered malocclusion.
In 1899, Dr. Edward Angle introduced a classification of malocclusion based on the relationship of the maxillary and mandibular first permanent molars.
What is this system known as? (The Angle classification of malocclusion.)
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10. Fig. 60-1 A, Diagram showing class I occlusion
Fig A, Diagram showing class I occlusion. B, Photo showing class I occlusion. (A, From Proffit WR, Fields HW: Contemporary orthodontics, ed 4, St Louis, 2007, Mosby.) B
Class I malocculsion is also known as neutroclusion. The facial profile is known as mesognathic.
What should be used as a guide if one or both of the first molars are missing from the side that is being classified?
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11. Class II Malocclusion
This condition is also referred to as istoclusion.
The body of the mandible is in an abnormal distal relationship to the maxilla.
Class II malocclusion causes the maxillary anterior teeth to protrude over the mandibular anterior teeth.
The facial profile is known as retrognathic.
The maxilla protrudes.
The lower lip is full and often rests between the maxillary and mandibular incisors.
The mandible appears retruded or weak.
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12. Fig. 60-2 A, Diagram showing class II malocclusion
Fig A, Diagram showing class II malocclusion. B, Photo showing class II malocclusion. (A, From Proffit WR, Fields HW: Contemporary orthodontics, ed 4, St Louis, 2007, Mosby.) B
Molar relation: The buccal groove of the mandibular first molar is distal to the mesiobuccal cusp of the maxillary first molar by at least the width of one premolar.
Canine relation: The distal surface of the mandibular canine is distal to the mesial surface of the maxillary canine by at least the width of one premolar.
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13. Class III Malocclusion
This condition is also referred to as mesioclusion.
The body of the mandible is in an abnormal mesial relationship to the maxilla.
Class III malocclusion causes the mandibular anterior teeth to protrude in front of the maxillary anterior teeth.
The facial profile is known as prognathic.
The lower lip and mandible are prominent.
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14. Fig. 60-3 A, Diagram showing class III malocclusion
Fig A, Diagram showing class III malocclusion. B, Photo showing class III malocclusion. (A, From Proffit WR, Fields HW: Contemporary orthodontics, ed 4, St Louis, 2007, Mosby.) B
Molar relation: The buccal groove of the mandibular first molar is mesial to the mesiobuccal cusp of the maxillary first permanent molar by at least the width of one premolar.
Canine relation: The distal surface of the mandibular canine is mesial to the mesial surface of the maxillary canine by at least the width of a premolar.
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15. Malaligned Teeth Crowding Overjet
In this, the most common contributor to malocclusion, one or many teeth are involved in misplacement.
Overjet
An excessive protrusion of the maxillary incisors results in space or distance between the facial surfaces of the mandibular incisors and the lingual surface of the maxillary incisors.
(Cont’d)
Crowding or overlapping makes oral hygiene (brushing and flossing) more of a challenge for the patient.
Overjet is the horizontal distance between the labioincisal surfaces on the mandibular incisors and the linguoincisal surfaces of the maxillary incisors.
What instrument would you use to measure an overjet? (Probe.)
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16. Malaligned Teeth Overbite Open bite Crossbite
(Cont’d)
Overbite
This is an increased vertical overlap of the maxillary incisors.
Open bite
A lack of vertical overlap of the maxillary incisors results in an opening of the anterior teeth when occluded.
Crossbite
A tooth is not properly aligned with its opposing tooth.
Overbite is the vertical distance by which the maxillary incisors overlap the mandibular incisors. It has three classifications: normal, moderate, and deep/severe.
Crossbites occur when the maxillary or mandibular teeth are either facial or lingual to their normal position.
What is the condition called when the mandibular anterior teeth are occluded anteriorly or facially to the maxillary anterior teeth? (Underjet.)
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17. Benefits of Orthodontic Treatment
Psychosocial
Oral function
Dental disease
Severe malocclusion and dental facial deformities can be a social handicap.
Oral function is influenced when malocclusion compromises chewing, jaw movement, speech, and temporomandibular joint function.
What could be affected if the oral-function needs of the patient are not fulfilled?
What could be affected if the need to have a healthy and sound dentition is not achieved?
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18. Management of Orthodontic Problems
Preventive orthodontics
To prevent or eliminate irregularities and malpositioning in the developing dentofacial region
Interceptive orthodontics
To intercede or correct problems as they are developing
Corrective orthodontics
To move teeth and correct malocclusion and malformations.
Corrective orthodontics includes fixed appliances, removable appliances, and orthognathic surgery.
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19. Orthodontic Records and Treatment Planning
Medical and dental history
Evaluation of physical growth
Social and behavioral evaluation
Clinical examination
What might the medical and dental history reveal about a patient’s orthodontic condition or needs?
Why is an evaluation of physical growth necessary?
Why is a social and behavioral evaluation necessary?
Clinical evaluation includes evaluation of facial aesthetics, oral health, and jaw and occlusal function.
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20. Clinical Examination Used to document, measure, and evaluate the:
Facial aspects
Oral health
Jaw and occlusal relationship
Functional characteristics of the jaws
Facial symmetry is assessed, including frontal and profile evaluations.
The jaw and the occlusal relationship between the teeth and jaws are key to determining an orthodontic treatment and strategies.
Functional characteristics of the jaws are also inspected. Lateral or anterior shifts of the mandible on closure are of special interest.
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21. Diagnostic Records Photographs are useful as an aid in:
Patient identification
Treatment planning
Case presentation
Case documentation
Patient education
Two standard extraoral photographs are taken: frontal view and profile view.
Three standard intraoral photographs are required: full direct view, maxillary occlusal view, and right buccal view.
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22. Fig. 60-9 A and B, Standard extraoral photographs
Fig A and B, Standard extraoral photographs. (From Proffit WR, Fields H, Sarver DM: Contemporary orthodontics, ed 4, St Louis, 2007, Mosby.)
The photo on the left is the profile view.
The photo on the right is the frontal view.
What visual aspects are noted on these photographs? (Jaw size, jaw shape, and jaw symmetry.)
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23. Fig A-C Intraoral photographs showing (A) the patient’s front view in occlusion, (B) the maxillary occlusal view, and (C) the right buccal view.
A, Front view shows the relationship between the anterior teeth including the overjet, overbite, and whether an open bite exists.
B, Occlusal view of the maxillary arch shows crowding and or overlapping, occlusal wear, and malalignment of teeth.
C, Right buccal view shows crossbites, openbites, and molar and canine relationship.
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24. Radiographs Cephalometric radiographs Cephalometric analysis
Extraoral radiographs make it possible to evaluate the anatomic bases for malocclusion, as well as the skull, bones, and soft tissue.
Cephalometric analysis
Tracing or computerized drawing involving a series of points makes it possible to compute a means of mathematical descriptions and measurement of the status of the skull.
The cephalometric radiograph is the most commonly used radiograph in orthodontic evaluation.
The analysis of the radiograph is completed by the marking of cephalometric landmarks at a series of points to determine skull size and shape.
These measurements reveal skull-growth patterns, which will determine the type of orthodontic treatment.
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25. Fig. 60-11 A and B Cephalometric radiograph and analysis.
The cephalometric radiograph is a profile or lateral view. It is taken at different intervals: before, during, and after orthodontic treatment.
The radiographs can be superimposed over each other to demonstrate jaw growth.
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26. Diagnostic Models Diagnostic models Diagnosis Case presentation
Diagnostic models are also called study models. Diagnostic models are used for the diagnosis and case presentation of the orthodontic patient.
Diagnostic models are made from plaster after an alginate impression of the patient’s mouth is taken. Models are often fabricated before orthodontic treatment and again after it is completed.
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27. Chapter 60
Lesson 60.2
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28. Learning Objectives Describe the components of the fixed appliance.
Place and remove brass wire separators.
Place and remove steel separating springs.
Place and remove elastomeric ring separators.
Assist in the fitting and cementation of orthodontic bands.
Assist in the direct bonding of orthodontic brackets.
(Cont’d)
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29. Learning Objectives Place an arch wire.
(Cont’d)
Place an arch wire.
Place and remove ligature ties.
Place and remove elastomeric ties.
Describe the use and function of headgear.
Describe ways to convey to the patient the importance of good dietary and oral hygiene habits in orthodontic treatment.
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30. Specialized Instruments and Accessories
Intraoral instruments
Orthodontic scaler
Used in bracket placement, removal of elastomeric rings, and removal of excess cement or bonding material
Ligature director
Used to guide the elastic or wire ligature tie around the bracket and to tuck the twisted and cut ligature tie under the arch wire
(Cont’d)
Numerous intraoral instruments are used, including orthodonic scalers, ligature directors, the band plugger and bite stick, bracket-placement tweezers, and pliers.
The ligature director is used with a push stroke to place the ligature where it is needed around brackets and bands.
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31. Specialized Instruments and Accessories
(Cont’d)
Band plugger
Used to help seat a molar band for a fixed appliance
Bite stick
Bracket-placement tweezers
Used to carry and place the bonded bracket on the tooth
The band plugger is the instrument used to seat molar brackets. This instrument is important because bands fit snugly and would be difficult to seat by simply pressing them down with a finger.
The bite stick is also helpful in the seating of bands. The patient occludes on the bite stick, which also helps seat the snugly fitting molar bands through the gentle use of occlusal forces.
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32. Fig. 60-13 A to E, Intraoral instruments
Fig A to E, Intraoral instruments. (From Boyd L: Dental instruments, a pocket guide, ed 3, St Louis, 2009, Saunders.) A C B D
Care must be taken in the sterilization of hinged instruments such as the bracket tweezer.
What is the most common result when hinged instruments are sterilized incorrectly? (Corrosion or rust around the hinged area.) E
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33. Specialized Instruments and Accessories
(Cont’d)
Pliers
Bird‑beak pliers
Used to form and bend wires
Contouring pliers
Used in fitting bands
Weingart utility pliers
Used in placing arch wires
Three‑prong pliers
Used to close and adjust clasps
Bird-beak pliers are used to bend wires for both removable and fixed appliances.
Contouring pliers have a bent beak. The bent beak aids in the placement of molar and posterior bands.
What are Weingart utility pliers?
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34. Specialized Instruments and Accessories
(Cont’d)
Posterior band–remover pliers
Used to remove bands
Pin and ligature cutter
Cuts the ligature wire for removal
Howe (110) pliers
Allows placement and removal of, and the making of adjustment bends in, the arch wire
Pin and ligature cutters are used to cut the ligature wire once it has been ligated around the bracket.
Howe (110) pliers are versatile because of their design. They have a round, flat, wide tip, making them suitable for holding orthodontic materials and appliances intraorally.
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35. Specialized Instruments and Accessories
(Cont’d)
Wire-bending pliers
Used to hold, bend, and adjust arch wires to create movement
Ligature‑tying pliers
Used for ease in ligature tying
Wire-bending pliers have notched areas throughout the beak to make it easier to bend wire while holding the wire securely in the pliers.
Ligature-tying pliers have finely serrated narrow beaks for ease in ligature tying.
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36. Fig. 60-14 A to I, Orthodontic pliers
Fig A to I, Orthodontic pliers. (Courtesy of Miltex, Inc, York, Pa.)
Top row: (A) Bird beak pliers, (B) contouring pliers, (C) Weingart utility pliers, (D) three-prong pliers, (E) posterior band remover.
Bottom row: (F) Ligature pin and ligature cutter, (G) Howe (110) pliers, (H) wire-bending pliers, (I) ligature-tying pliers.
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37. Fixed Appliances
Fixed appliances, also referred to as braces, are a combination of bands, brackets, and auxiliaries that can be used to move a tooth in six directions: mesially, distally, lingually, facially, apically, and occlusally.
Fixed appliances are cemented to the teeth and cannot be removed by the patient.
Auxiliaries, such as hooks and tubes, are also attached to brackets and bands.
The arch wire is attached to all brackets and exerts opposing forces on the teeth to cause them to move.
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38. Fig Full braces.
Can you name the pieces of the fixed appliances shown on this slide?
What will become an increased challenge to this patient on a daily basis?
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39. Sequence of Appointments for Fixed Appliances
Placement of separators
Cementation of molar bands
Bonding of brackets
Insertion of arch wire and tying in with ligature ties or elastomeric ties
Adjustment checks
Removal of appliance
Retention of teeth
The sequence of events in the orthodontic treatment plan may vary slightly from patient to patient.
After the data have been collected, diagnostic records have been assembled, and clinical evaluation is complete, the orthodontist will outline the treatment sequence, including how and when the orthodontic appliances will be placed in the patient’s mouth and later removed.
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40. Separators
Teeth are separated before fitting and the placement of the molar bands.
Brass-wire separators
Steel separating springs
Elastomeric separators
How do you place the separator?
Who places the separator?
How do you remove the separator?
Who removes the separator?
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41. Orthodontic Bands
Preformed stainless steel bands are fitted and cemented to molar teeth.
Buttons, tubes, and cleats are attached for the arch wire and power products.
How is an orthodontic band placed?
Who places the band?
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42. Fig. 60-16 Varying sizes of bands.
Orthodontic bands come in a variety of sizes.
Bands are most commonly placed on molars.
The occlusal aspect of the band is slightly rolled or contoured.
The gingival aspect of the band is straight and smooth.
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43. Bonded Brackets
On the bonded bracket, the arch wire is placed horizontally through the wings of the bracket and then ligated in place.
This stabilization initiates tooth movement by allowing the forces from the arch wire to be transmitted to the tooth.
The bonded bracket is the most common type of attachment for fixed appliances.
Brackets are placed in a number of ways, depending on the teeth in question.
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44. Fig. 60-18 Bracket ready for placement.
Brackets vary in size according to the teeth to which they will be bonded.
Notice the four tie wings on each of the brackets.
What is the purpose of the tie wings?
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45. Auxiliary Attachments
Headgear tubes
These round tubes, routinely placed on maxillary first molar bands, are used for the insertion of the inner bow of a facebow appliance.
Edgewise tubes
Rectangular tubes are placed on the buccal surfaces of the upper and lower first molar bands to receive the arch wire.
(Cont’d)
Headgear is usually a removable appliance inserted and removed by the patient as recommended by the orthodontist.
Edgewise tubes are an integral part of contemporary orthodontic procedures.
Edgewise tubes are rectangular and hold the arch wire securely.
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46. Auxiliary Attachments
(Cont’d)
Labial hooks
Located on the facial surfaces of the first and second molar bands for both arches, these hooks hold the interarch elastics.
Lingual arch attachment
This button or bracket, located on the lingual portion of the bands, stabilizes the arch and reinforces anchorage and tooth movement.
In addition to the use of arch wires and ligatures to provide forces to encourage teeth movement, elastics are used.
Elastics extend to and from various hooks attached to the facial surfaces of bands and brackets.
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47. Arch Wire
Preformed thin wire is placed within the bracket to provide a pattern for the dental arch to take its shape from and to guide the teeth in movement.
The arch wire fits into a horizontal slot in the brackets or slides into the buccal tubes on molar teeth.
Arch wires come in a variety of diameters, which affect the magnitude of the force that is applied to the teeth.
(Cont’d)
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48. Arch Wire Types of arch wires Nickel-titanium Stainless-steel wire
(Cont’d)
Types of arch wires
Nickel-titanium
For movement because of its flexibility
Stainless-steel wire
Stiffer and stronger
Beta titanium (TMA)
Provides a combination of strength, flexibility, and memory
Optiflex
Used for light force and its aesthetics
Nickel-titanium wire is used during initial stages of tooth movement for malaligned or crowded teeth.
Stainless-steel wire is used to apply more force and give better stability to control the teeth. It can withstand greater forces and is known as the working arch wire.
Optiflex wire is a newer type of arch wire made from composite materials with a top coating of optical-glass fibers.
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49. Arch Wire Shapes of arch wires
(Cont’d)
Shapes of arch wires
Round wires are used in the initial and intermediate stages of treatment to correct crowding, level the arch, open a bite, and close spaces.
Square or rectangular wires are used during the final stages of treatment to position the crown and root in the correct maxillary and mandibular relationship.
The shape of the arch wire used is determined by the treatment and movement needed during each stage of the orthodontic procedures.
The shape of the arch wire is also determined by the current phase of the treatment.
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50. Ligature Ties Stainless steel Kobayashi hooks
A gauge stainless-steel wire ligature is used to “tie” in arch wires.
Kobayashi hooks
Ligature ties that have been spot welded at the tip form hooks for the attachment of elastics.
Arch wires are anchored into the brackets by ligature ties.
Ligature ties may be made of thin wire or tiny elastic bands.
The orthodontist may assign individual brackets to be tied with individual ligatures or an entire quadrant or sextant tied with one ligature.
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51. Elastomeric Ties
A small elastic ring stretched around a bracket is used to hold the arch wire in place.
Elastomeric ties are available in a variety of colors.
Elastic ties are also used to secure the arch wire to the brackets.
Young patients like the elastic ties because they come in a variety of colors.
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52. Power Products Elastic chain ties Elastics
These ties, continuous O’s that form a chain, are used to close space between teeth or correct rotated teeth.
Elastics
Commonly referred to as rubber bands, elastics are placed from one tooth to another in the same arch or from one tooth to another tooth in the opposing arch. Elastics help close spaces between teeth and correct occlusal relationships.
(Cont’d)
Power products are accessory items made of elastic materials that aid tooth movement.
These power products are attached to the fixed appliances by being placed over the brackets or attached to labial hooks or lingual arch attachments.
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53. Power Products
(Cont’d)
Elastic thread is a type of tubing used to close space or aid in the eruption of impacted teeth.
Comfort tubing aids in patient comfort by covering an arch wire that may be causing discomfort.
It is important to avoid using power products containing latex materials because of the increased incidence of latex sensitivity among operators, dental assistants, and patients.
Instruments used to place elastic power products include the hemostat and orthodontic scaler.
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54. Headgear
Headgear is an orthopedic device used to control growth and tooth movement.
Facebow
Used to stabilize or move the maxillary first molar distally and create more room in the arch.
Traction device
Used to apply the extraoral force necessary to achieve the desired treatment results
Headgear is composed of two parts: (1) The facebow is inserted into headgear tubes, which are attached to the buccal aspect of molar orthodontic bands. (2) The traction device may be one of a variety of styles, depending on the force needed to move the maxillary arch.
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55. Fig. 60-23 Four types of traction.
Upper left: Chin-cap traction device is a combination of a high-pull strap and chin cup to help control the growth of the mandible in patients with class III malocclusion.
Lower right: The combination headgear traction device is a combination of a high-pull and a cervical-traction device. It exerts a force along the occlusal plane and upward.
What is the headgear in the upper right image?
What is the headgear in the lower left image?
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56. Oral-Hygiene Instructions
Toothbrushing instructions
Floss your teeth, using a floss threader for easy application.
Brush your teeth at least once every day.
After brushing, rinse and swish water around to remove any debris.
Inspect your teeth and braces carefully to make sure that they are spotless.
The biggest day-to-day challenge faced by a patient with full-mouth fixed orthodontic appliances is plaque control and maintenance of a healthy mouth.
Orthodontic appliances offer areas for food and plaque to be trapped and hidden.
What will result from poor oral hygiene?
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57. Table 60-2 Dietary Habits and Orthodontics
Besides good oral-hygiene habits, the orthodontic patient must also develop good eating habits.
Healthy foods and good eating habits will help maintain healthy teeth and gingiva and will also prevent damage to the orthodontic appliances.
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58. Retention Orthodontic positioner
Retains the teeth in their desired positions
Permits the alveolus to rebuild support around the teeth before the patient wears a retainer
Massages the gingiva
(Cont’d)
After removal of the fixed appliances, the orthodontic treatment is not complete.
The orthodontic positioner is a custom-made appliance constructed of rubber or pliable acrylic that fits over the patient’s dentition after orthodontic therapy.
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59. Retention Hawley retainer Lingual retainer
This removable retainer is worn to passively retain the teeth in their new position.
Lingual retainer
A fixed lingual wire bonded canine to canine on the lingual surfaces provides lower-incisor position during late growth.
The Hawley retainer is the most commonly used removable retainer.
The Hawley retainer is made of a clear self-polymerizing acrylic that is designed to hold wire clasps on molar teeth.
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