Esthetic orthodontic applainces /certified fixed orthodontic courses by Indian dental academy

ESTHETIC ORTHODONTIC
APPLIANCES

www.indiandentalacademy.com

CONTENTS
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


Introduction
Evaluation of esthetics
Evolution of orthodontic materials
Tooth colored brackets
Esthetic arch wires
Elastomeric Ligatures
Tooth colored Ligatures
Tooth colored appliances
Lingual Orthodontics

Introduction:




Aristotle said "Beauty is a greater
recommendation than any letter of
introduction".

The term “Esthetic” refers to an
understanding of beauty.






Esthetics which is derived from greek
word for “aisthetikos”, deals with beauty
and the beautiful.

Lombardi defined “Dental Esthetics” by
the way things were perceived visually.


Visual perception

Proportion

Composition




Harmony between the dominant features
of a face contributes to creating a beautiful
face.



The "Facial Dominant Features" are

1.

Smile with its components.
Teeth, gingiva and lips.
Eyes and facial frame.

2.
3.


Golden Proportion
Beautiful Proportion




Greeks who tried to formulate beauty as an
exact mathematical concept.
"Golden Proportion” – Leonardo da vinci
The Golden Proportion, phi, has been observed to
evoke emotion or aesthetic feelings within us. The
ancient Egyptians used it in the construction of the great
pyramids and in the design of hieroglyphs found on
tomb walls. At another time, thousands of miles away,
the ancients of Mexico embraced phi while building the
Sun Pyramid at Teotihuacan.







The Greeks studied phi closely through their
mathematics and used it in their architecture
Renowned artists such as Michelangelo, Raphael, and
Leonardo da Vinci made use of it for they knew of its
appealing qualities.
Evidence suggests that classical music composed by
Mozart, Beethoven, and Bach embraces phi.

"Beautiful Proportion” – Plato
"The good, of course, is always beautiful, and
the beautiful never lacks proportion”- Plato

Evaluating esthetics in Dentist’s chair
Lombardi remarked that detailed esthetic
judgments can only be made by viewing
patients from front, in conversation, using
facial expressions, and smiling.


Evaluation of facial
&
Dental appearance


Face in three planes of space (Macro esthetics).



Smile frame work ( Mini esthetics).



The Teeth (Micro esthetics).


MACRO ESTHETICS


Asymmetry



Excessive or deficient face height



Imbalance in the facial profile.


MINI ESTHETICS


Gingival display on smile



Anterior tooth display



Gingival heights



Buccal corridors

MICRO ESTHETICS


Crown lengths of upper and lower incisors



Incisal edge contours



Midlines


Evolution of orthodontic materials


Like metallurgy, dentistry has a long history of artistic
creativity.



Over 4500 years ago when the metal worker was
sweating copper from malachite for weapons, making
primitive tools from „„bia‟ n pet‟‟ (meteoric iron), and
separating gold from crushed quartz stone literally using
what became known as the Golden Fleece, the
„„Toother‟‟ was likely splinting the teeth of the Egyptian
court.





Time passed from the Bronze Age to the Iron Age
and the Industrial Revolution until, in the latter half
of the 19th century
Henry Clifton Sorby (1863–1887) and Edward
Hartley Angle(1886–1930) professionally ascended
to become the pioneers of modern metallography and
modern orthodontics, respectively


THE BEGINNINGS








Teeth were regarded by the ancients as very precious to
the extent that „„. . . special penalties [were exacted] for
knocking out the teeth of an individual, either freeman or
slave.‟‟
As early as 400 BC, Hippocrates referenced in his
writings the correction of tooth irregularities
And while Greece was in its Golden Age, the Etruscans
(the precursors of the Romans) were burying their dead
with appliances that were used to maintain space and
prevent collapse of the dentition during life.
Then in a Roman tomb inEgypt, Breccia finds a number
of teeth bound withwww.indiandentalacademy.com
a gold wire



And at the time of Christ, Aurelius Cornelius Celsus first
records the treatment of teeth by finger pressure

EARLY CONTRIBUTORS






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The French and English dominated the earliest
contributions to the field of orthodontics, which as yet
had not been formally named
In 1819 Delabarre introduces the wire crib, and this
marks the birth of contemporary orthodontics
In the second half of the 19th century(ca 1865), Kingsley
advocates plates as retaining devices
In the early part of the 20th century, Angle would tout
this device as one of the best tooth maintainers

Products made from alloys that orthodontics adopted. (A) 1936 Ford sedan made from
stainless steel; (B) mainspring of a watch fabricated from cobalt-chromium alloy;
(C) hydraulic shape-memory coupling manufactured from nickel-titanium intermetallic
composition; and (D) SR-71 Blackbird constructed from titanium-molybdenum alloy

Orthodontic cases from yesteryear to
today.
(A) A fully banded patient with extensive
stainless steel (SS) loop mechanics,ca
1965;
(B) a patient fitted with maxillary
polycarbonate brackets and a TeflonYcoated SS archwire and mandibular SS
conventional brackets, ca 1980;

And (C) a patient with conventional
straight-wire
CP-titanium brackets, ca 1995 (F. Sernetz,
personal communication).

ESTHETIC BRACKETS


A)Plastic brackets
1) Polycarbonate brackets
2) Polyurethane-composite brackets
3) Thermoplastic-polyurethane brackets
B) Ceramic brackets
1) Monocrystalline alumina (Sapphire)
2) Polycrystalline alumina
3) Polycrystalline Zirconia (YPSZ)


PLASTIC BRACKETS




The percentage of orthodontic patients increased dramatically
in mid 80s to 25 % total orthodontic patients



Early commercially available aesthetic products included both
plastic brackets and ceramic brackets



The first transparent bracket material-1960(Newman)



The first plastic brackets were manufactured from unfilled
poly carbonate (early1970s)

•

Initially an aesthetic alternative to metal brackets

But short lived,because
•

Staining and odour

•

Lack of strength and stiffness

•

Tie wing fractures

•

Permanent deformation(creep) over constant load

•

Poly carbonate bracet slots distorted with time uder aconstant
physiologic stress(2000 gm-mm)



Sadat-Konsari et al study on torque deformation characteristics
of seven commercially available plastic brackets (metal slot
reinforced bracket,poly urethane,pure poly carbonate and fiber
glass reinforced in plastic brackets) that,



plastic brackets are only suited for clinical application if they
have a metal slots




Plastic brackets are not as hard as ceramics, a fact which may
be an advantage rather than a disadvantage.



Since it is generally thought that the harder a material is, the
more it will wear an opposing material softer than Itself
(Monasky.1971).



Plastic brackets will not wear or chip enamel. if occluded
upon.


Bond strength


A wide variation exists in the results of different studies on
bond strength with regard to the types of brackets, so that
direct comparison of results is not feasible.

The factors that may contribute to these differences include



the choice of composite,



the type of testing equipment used,



-the orientation of the applied force,



-the storage medium of the extracted teeth,



-the bracket material, and



-whether the bracket base has a mechanical or chemical

union to the composite resin (Crow. 1995).


•

These materials are not cross-linked and the brackets may
also undergo drifting when subjected to temperatures
slightly higher than those In the mouth

•

Diacrylate cements used with plastic brackets were found
not to bond well to them without plastic bracket primers

•

A bonding system, based on a unique thermosetting
combination of mono- and dia-crylates and a high
molecular weight polymeric filler, was developed to
Improve the bond strength of polycarbonate brackets



At present the new generations of plastic brackets are suitable
for almost all adhesive systems.



No-mix adhesives or light-cure bonding materials with a
supplementary primer are recommended by the orthodontic
companies.



The adhesives with their own plastic primer demonstrated
higher bond strength values than those without plastic primer



Satisfactory bond strength values were observed for
polycarbonate brackets with no-mix orthodontic bonding resins
and highly filled, self cured diacrylate cements (Blalock and
Powers, 1995 Nkenke e1 al.. 1997)




Among the factors that may cause these differences are
geometry of the wings, presence of metallic reinforcement,
sharp edges and geometry of the base.



Large and thick bases, rounded contours and provision for
mechanical retention were factor associated with improved
bond strength with the plastic brackets



The new ranges of plastic brackets offer a mechanical locking
base, providing more bonding surface for mechanical retention
with the adhesive.


Torque properties









Harzer et al reported significantly higher torquing losses and
lower torquing moments with polycarbonate brackets
So that additional torque should give
To compensate strength problems ,
High grade medical poly urethane brackets ,
poly carbonate brackets reinforced with ceramic or fiber glass
fillers and /or metal slots
Although torqueproblems exists.(15% torque loss over 24hrs
has been observed both ceramic reinfforced and metal lined
poly carbonate brackets

Disadvantage polycarbonate brackets
•

•

•

Polycarbonate brackets undergo creep deformation when
transferring torque loads generated by arch wires to the teeth
Discoloration of first generation unfilled polycarbonate
brackets during clinical aging.
They absorb water to a slight extent and tend to weaken in
the course of about one year (Newman 1973).


•

Most efforts are directed toward improving the strength of
polymeric brackets by reinforcing the plastic matrix.

•

Various reinforced polycarbonate brackets were,
1)
Polymer fiber reinforced polycarbonate brackets
2)
Fiberglass reinforced polycarbonate brackets
3)
Ceramic reinforced polycarbonate brackets
4)
Metal slot reinforced polycarbonate brackets
5)
Metal slot and ceramic reinforced polycarbonate brackets


Commercially available plastic brackets
Poly carbonate –glass fibers
1)
Aesthetic Line
2)
Image
Poly carbonate-composite
DBfibre
Elan
Poly urethane composite
Envision
Thermoplastic poly urethane
Value line

Poly carbonate brackets
Elation TM

(GAC)


Fiber-Reinforced Polycarbonate brackets
Spirit®MB

(ORMCO)

Classic (American Orthodontics)

Fiber-Glass reinforce composite polymer
OysterTM Bracket (GAC)
VogueTM


(GAC)

Commercially available plastic brackets


Ceramic brackets


Ceramic Brackets


Ceramics used for the manufacturing of ceramic brackets
were Alumina and Zirconia. Both can be found as
tridimensional inorganic macromolecules.

Types of ceramic brackets
 Monocrystalline (Sapphire)
 Polycrystalline Alumina
 Polycrystalline Zirconia-Yttrium oxide Partially Stabilised
Zirconia (YPSZ)




b2"
Al3+

Al3+

b1

O2O2-

O2-

2

Al3+

b"

O

2-

Al3+

3

Al3+

b'
1

Al3+

O2-

O2-

Aluminium oxide crystal structure
consists of a nearly Hexagonal
close pack (HCP) arrangement of
the larger oxygen anions (O2-),
with smaller aluminium cations
(Al3+), located in two- thirds of the
octahedral interstitial sites in the
HCP structure.These octahedral
sites have six-fold coordination,
i.e.,each aluminium ion is
surrounded by six oxygen ions


Manufacturing process
Mono crystalline brackets:
Heating aluminum oxide to temperatures in excess of 2100 c
Then, cooled slowly, and the bracket is machined (sintering
process)
-

From the resulting crystal cut them in different shapes and
dimensions of various brackets, using ultrasonic cutting
techniques, diamond cutting, or combination of two


Poly crystalline brackets:
-manufactured by blending
aluminum oxide particles
with a binder
-temperatures above 1800 c
are used to burnout the
binder and fuse together and
fused together the particles
of the molded mixture
Then ,
it is heat treated to remove
surface imperfections and
relieve stresses created by
the cutting operation www.indiandentalacademy.com


Advantage of the process:A relatively inexpensive process that yields large quantities

Disadvantage this process
- Presence of structural imperfections at grain boundaries or
of trace amounts of impurities

Impurities in quantities as minute as 0.001 percent or slight
imperfections can serves as foci for crack propagation under
stress





Alternative method of making polycrystalline brackets is
injecting molding
Advantage is eliminates structural imperfections created by
cutting process


Disadvantage of poly crystalline brackets



The larger the ceramic grains ,the greater the translucency.
But,
as the grain size increases the material tends to be weaker.
it is up to 30 microns

Poly crystalline brackets begins as aluminum particles of
about 0.3 microns reached 20-30 microns.


Zirconium brackets






Zirconium is a mineral extracted from beach sands of
AUSTRALIA
The PSZ (partially stabilized zirconium) developed by the
common wealth scientific and industrial research
organization(CSIRO)as a reliable highly stress –resistant
material
Greatest toughness among all the ceramics


Properties of zirconium brackets






Greatest toughness
Cheaper
Good sliding properties for stainless steel and nickel titanium
arch wires
Reduced plaque adhesion


Base Characteristic of Ceramic Brackets


two types of ceramic bracket bases are available

Bonding mechanisms that have been identified for ceramic
brackets may be classified into three major categories:
a)
Mechanical retention employing large recesses.
b)
Chemical adhesion facilitated by the use of a silane layer.
c)
Micromechanical retention through the utilization of a
number of configurations, including protruding crystals,
grooves, a porous surface, and spherical glass particles.



1. bracket base is formed with undercuts or grooves that provide
a mechanical interlock to the adhesive.
 The mechanical retention of such brackets is less as compared
to other bracket base that are having both micromechanical
retention and chemical adhesion.
2.Bracket base has a smooth surface and relies on a chemical
coating to enhance bond strength.
 A silane coupling agent is used as a chemical mediator
between the adhesive resin and the bracket base.
 It has been claimed that chemical adhesion provided higher
bondstrength when compared with mechanical

Silane coating of bracket bases






The coupling agent -methacryl oxypropyl trimethoxy silane
( -MPTS) has been used for promoting chemical adhesion
between surfaces.
The -MPTS is hydrolysed to the corresponding silanol. A
limited number of silanol groups per silanol molecule are
hydrogen-bonded to the water layer adsorbed on the base
surface.
Side chain silanols are condensed, establishing a siloxane
network that stabilizes the structure.




Owing to the silanol orientation toward the bracket base,
methacrylate groups are placed in a configuration that favours
cross-linking with the methacrlate-based adhesive.

Bonding arises from two mechanisms:


Silanol groups of the hydrolysed silane adhere to the hydration
layer of the inorganic surfaces



Methacrylate groups of the silane copolymerize with the
methacrylate resin matrix, forming covalent bonds

Recently another two
developments………


polycrystalline alumina with a rough base comprised of
either randomly oriented sharp crystals or spherical glass
particles.



These brackets provide only micromechanical inter locking
with the orthodontic adhesive



In an attempt to overcome the potential damage of enamel
during debonding, a ceramic bracket with a thin
polycarbonate laminate coating on the base has been
manufactured (CeramaFlex, TP Orthodontics)


Ceramic brackets with different base types
Viazis (1990) compared the shear bond strength for two types of
ceramic brackets and concluded that,
The shear bond strength of silane chemical bonded ceramic
brackets is significantly higher than the grooved mechanical
bonded ceramic brackets.


Physical Properties of Ceramic Brackets


Hardness,



Tensile strength and



Fracture toughness or brittleness


Hardness of ceramic and enamel wear





Extremely high hardness due to aluminum oxide
Ceramic brackets are 9 times harder than stainless steel or
enamel(Swartz1988)
Douglass (1989) gave a clinical report of enamel damage
found on the lingual surfaces of maxillary central incisors
that were in contact with poly-crystalline sapphire ceramic
brackets placed on the facial surfaces of lower incisors. This is
because, when natural tooth surfaces have opposing contact
with ceramic brackets in occlusion, due to the hardness of
ceramics enamel damage may occur.


Tensile strength






Tensile strength is much higher in mono crystalline alumina
than in poly crystalline alumina
Tensile strength characteristics of ceramics depend on the
condition of the surface of the ceramic
Metal brackets deforms 20% under stress before fracturing
whereas ,ceramic brackets deforms less than 1% before failing.


Fracture Toughness or Brittleness


Ceramics used in orthodontic brackets have highly
localized, directional atomic bonds. This oxidized atomic
lattice does not permit shifting of bonds and redistribution
of stress.



When stresses reach critical levels, the interatomic bonds
break and material failure occurs. This is called “brittle
failure”.




Fracture toughness is a measure of the strain energyabsorbing ability prior to fracture for a brittle material. The
higher the fracture toughness, the more difficult it is to
propagate a crack in the material.



Vickers hardness testing machine is used to test the fracture
toughness of ceramic brackets. Microscopic indentations are
placed on the surface of bracket and the associated cracks at
the tip of the indentation are evaluated.




Fracture behaviour is controlled by the influence of surface
cracks and other microscopic defects or internal pores. These
are called “Griffith flaws”.



Fracture toughness of ceramics is 20 to 40 times less than that
of stainless steel (Scott 1988)


•

•

1.
2.

The brittle nature of ceramic brackets has resulted in a
higher incidence of bracket failure (fracture) during
debonding Ceramic compounds, unlike metals, are also
susceptible to crack propagation
The combination of very hard and brittle properties and high
bond strength leads to reports of two significant problems.
Bracket fracture specifically during debonding
Enamel fracture which may occur during function but mostly
during debonding.


Optical properties
•

Single crystal brackets are clearer than polycrystalline
brackets.
The sintering process produces a polycrystalline
alumina microstructure with grain boundaries, resulting in
some translucency.

•

There is loss of light transmission through the ceramic .

•

Optical properties and strength are inversely related for the
polycrystalline alumina ceramics .

Photograph showing difference in optical clarity
between plastic bracket and ceramic bracket assigned
to decreased light transmittance of polymeric appliance

Why Enamel and Bracket Get Fracture?


Enamel fractures is due to the high bond strength of ceramic
brackets.



However, most of the adhesives available in the market have
adequate bond strength to resist orthodontic forces.


SEM (25x) image showing enamel surface
SEM (25x) image showing enamel
after
fracture after
debonding Inspire bracket. ARI score 5.
shear bond test, Inspire bracket. www.indiandentalacademy.com

SEM (25x) image showing bracket fracture on
tooth surface, Inspire bracket

Frictional Resistance
•

•

•

•

•

Polycrystalline brackets have a higher co-efficient of friction
than monocrystalline ceramic and stainless steel
This is due to their rougher and more porous surface.
Ceramic brackets manufactured by machining - significantly
greater rough surface.
Omana, Moore and Bagby reported that
ceramic brackets manufactured by injection-molding
technique had less friction than other ceramic brackets.
They also found that wider brackets had less friction than
narrower brackets

Tie-wing strength
•

Photoelastic studies and finite-element analyses have shown
that
tie-wings are generally the locations of concentrated stresses
when forces are applied to the ceramic brackets.



Tie-wing fractures have been much more common for the
single-crystal alumina brackets because of their lower
resistance to crack propagation.




Sonneveld et al (1994)
compared the breaking force in compression for alumina
and zirconia brackets and found that zirconia brackets did not
experience any tie wing fractures, but instead underwent
visually perceptible deformation prior to bulk fracture.




Research using finite element analysis has indicated that
brackets possessing an isthmus connecting the tie-wings
demonstrated better stress tolerance than those without this
feature.


Commercially available ceramic
brackets
Monocrystalline alumina
1) Inspire
2) Starfire TMB
Polycrystalline alumina
1) Allure
7) Mxi
2) Clarity
8) Signature
3) Fascination
9) Virage
4) Intrigue
10) CeramaFlex (with polycarbonate
base)
5) 20/20
11) InVu
6) Lumina
Polycrystalline zirconia
1) Hi-Brace

Facial (A), lingual (B), and profile (C) views of the
MXi ceramic bracket


Facial (A), lingual (B), and profile (C) views of the Clarity ceramic bracket.
88

GAC International introduces the InOvation® C, seif ligated

LeoneAmerica introduces AQUA™
ceramic brackets.slot is crystal gloss


Experimental brackets: left, UDMA bracket without
filler; center, UDMA bracket with 40% by volume
silicon dioxide filler; right, UDMA bracket with 70% by
volume silicon dioxide filler.


Nd: YAG laser for debonding ceramic
orthodontic brackets
Kotaro Hayakawa

Lasing positions, polycrystalline bracket


Experimental setup and laser delivery.


This study on the effects of Nd:YAG laser irradiation
on ceramic brackets on bovine teeth produced the
following findings.
1.
The application of a high-peak power Nd:YAG laser at 2.0 or
3.0 J notably weakened or eliminated the bond strength.
•

2. At the 2.0-J level, polycrystalline ceramic brackets exhibited a
significant decrease in bond strength compared with singlecrystal ceramic brackets


3. No significant differences were found among different
types of adhesive resins.
4. The rise in intrapulpal temperature as a result of lasing was
extremely low, and the maximum temperature increase was
5.1 C.


Bond strength and debonding characteristics of
a new ceramic bracket
Jia-Kuang

SEM (25x) images of 3 types of brackets with mechanical base. A, Inspire; B, Clarity;
C,metal

Stereoscope images showing 2 debonded ceramic
brackets from occlusal surface. A, Clarity; B,Inspire

Scanning electron micrographs of base surface of
brackets, before bonding; A, Begg ceramic bracket
(SEM x 24); B, Begg metal bracket (SEM x

Bracket Jacketz offers interchangeable clips for brackets, which
allow children to customize their smile with alphabetical letters

American Orthodontics offers Radiance brackets,
which are made from singlecrystal,pure grown
sapphire

Comfort Solutions offers soft caps designed from mouthguard
materialThe soft caps also provide comfort to patients who play
musical instruments and provide protection to incisal edges that
occlude against ceramic brackets.

Ortho-byte introduces Integra™ ceramic brackets

Ceramic bracket debonding techniques
1.Debonding lift of pliers
2.Hows or weingart pliers and ligature cutters
3.Special debonding pliers
4.Electrothermal debonding
5.Ultrasonic debonding
6.Laser debonding


1. Conventional method (Swartz 1988)
2. Electrothermal debonding (Sheridan 1986)
4. Ultrasonic debonding (Bishara and Trulove 1990)
5. Grinding method (Vukovich 1991)
6. Lift-off debracketing method (Reed and Shivapuja 1991)
7.Peppermint oil application (Winchester 1992)
8.Laser aided debonding using Nd: YAG laser (Strobl et al
1992),
- XeCl excimer laser (Tocchio, Williams and Mayer 1993),
- Carbon-di-oxide laser (Rickabough and Marganoni 1996).


Debonding lift-off pliers
Method:gentle squeezing pressure at the bracket/adhessive
interface

Advantages:
1.Quick and simple
2.Standard orthodontic instrument
3.Safest and most effective technique for ceramic bracket
removal

Disadvantages:
Increased debonding force
Risk of enamel damage
Risk of bracket fracture and aspiration of fragments

Plastic plier for debonding Inspire
brackets,
designed by Ormco

Weingart plier used to debond Clarity
ceramic
bracket. A mesiodistal force is applied to
tiewings of brackets at level of metal slot.

ETM plier used to debond MXi
ceramic brackets.
Blades are applied between
bracket base and enamel
surface.


Elecctro thermal debonding


Method :

Softening of the resin adhesive via a rechargeable heating gun
inserted into the bracket slot whilst applying a tensile force to
the bracket
Advantages:
Reduced debonding force
Reduced risk of enamel damage
Reduced incidence bracket fracture
Reduced patient discomfort


Disadvantages






Risk of pulpal damage
Risk of soft tissue burns
Expense of unit
Increased clinical time
Bracket failure may not occur at first attempt


Ultrasonic debonding
Method:
Ultrasonic instruments used to create a purchase point within the
adhesive between the bracket base and the enamel surface

Advantages:
Decreased chance of enamel damage
Removal of residual resin with same instrument


Disadvantages:


Time consuming



Excessive wear of ultrasonic tips



Water spry coolant required to minimise detrimental heating
effect on the pulp


Laser debonding
Method:


Irradiation of the buccal surface with laser light
Debonding occurs through thermal softening of the adhesive

Advantages :
Decreased chance of enamel damage
Potentially less traumatic and painful


Disadvantages:
Potential pulpal damage due to heat production
Expensive units laser hazards


Esthetic arch wires


Composite arch wire


Composed of S2- glass fibers & acrylic resin.

Manufacturing process:
Pultrusion is a continuous process of manufacturing
of composite materials with constant cross-section
whereby reinforced fibers are pulled through a resin,
possibly followed by a separate preforming system, and
into
a
heated
die,
where
the
resin
undergoes polymerization.

Many resin types may be used in pultrusion
including polyester, polyurethane, vinylester and epoxy.

Composite - properties


Esthetically pleasing because of their translucent
quality tends to transmit the color of host teeth.



Prototype have been constructed with stiffness
ranging from that of niti to beta titanium without
change in the cross sectional dimension.



When the fiber &resin content are equal ,spring back
is greater than 95% and the total water sorption is
only 1.5% by wt so that dimensional stability is good.

Esthetic retainer


Organic polymer retainer wires made up of poly
ethylene terephthalate 1.6 mm diameter.



To contour the material plier is used to bent and heated
for few secs of temp less than 230 C



In prefabricated wire –anterior portion (st) & posterior
portion (wave).



Shrinkage takes place during heating which
compensated by posterior segment.



No significant discoloration & does not absorb water.

Esthetic retainer- newer version


The anterior plastics part is a flat organic polymer
wire with 100 labial torque is attached to .032‟ ss
posterior arm each 11cm long.



The plastics comes in 3 inter canine with or without
activating omega loop in posterior arm.



It requires no special tool or instrument only on
ordinary hair hair dryer.

Fiber- Reinforced composite











FRC materials are superior to polymer because
they offer a structural rigidity & strength as well
as reduction in stress relaxation.
Modules of elasticity is 70% greater than that of
the highly filled dental composite.
Yield strength is 6 times greater than dental
composite.
24 times resilience than dental composite.
FRC can be bonded to another FRC and
attachment(brackets,hooks) can be added directly.
They are available in 3-different configurationround,strip & woven pattern.

FRC
MANUFACTURING PROCESS:
The fibers are correctly oriented and excellent
coupling is achieved ,followed by an initial
polymerization makes the matrix flexible and
adaptable, so it can be easily contained to the teeth.
The result is a user friendly polymer that is as
easily manipulated as any plastics, but as structurally
strong as metal.

Clinical application-FRC
Open bite cases.
 Space closure.
 Up righting molar.
 Maxillary anterior intrusion.
 Fixed lingual retainer.
Limitation:
They are weakest in shear & torsion.



OPTI-FLEX ARCH WIRE






Designed by Dr.Taloss & manufactured by
Ormco.
It is made up of :1) Silicon-di-oxide.
2) Silicon resin.
3) Nylon.
Available in 10‟‟ to 6‟‟ st lengths of 0.17‟‟ &
0.021‟‟.

Advantages of opti-flex








Most esthetic arch wire.
Stain resistant.
Light continuous force exerted( showed low
load deflection rates reaching the
proportional limit much earlier when
compared to other wires
More flexible.
It can be used in bracket system.

Disadvantages of opti-flex







Sharp bends are avoided.
Metal ligatures tie are avoided.
Special instruments are used to cut.
Rough diet are restricted.
This arch wire is not recommend for cuspid
retraction.


Teflon coated SS arch wire
Teflon is a commercial
synthetic resin
( polytetrafluoroethylene).
ADVANTAGE:
 Used to prevent wetting of the metal surface.
DIS ADVANTAGE:
 Does not discolor.
 Grayish hue of these wire makes them esthetically
inferior.
 Teflon coating wear off 2-3 weeks exposing the metal
surface.


Marsenol arch wire


Tooth colored niti wire manufactured by
glenroe technologies.



It is a E.T.E coated niti (Elastomeric poly tetra
florethylene emulsion)


Lee white wire








Manufactured by lee pharmaceutical.
To the niti or stainless steel tooth colored
Epoxy coating is bonded.
It is completely opaque and does not chip,
peel, stain or discolor.
Suitable for ceramic & plastics brackets.


ELASTOMERICS


ELASTOMERICS


Elastomer is a general term which
encompasses materials that after substantial
deformation rapidly returns to their original
dimensions.



Strictly speaking, elastic is an elastomeric
material whose threads are interwoven with
strands of rubber.

HISTORY OF DEVELOPMENT
Natural Elastomers - Natural rubber probably used by the
ancient Indian and Malay civilizations, was the first
known elastomer.


It had limited use because of its unfavorable temperature
behavior and water adsorption properties.



With the advent of vulcanization by Charles Goodyear in
1839, uses for natural rubber greatly increased.



Early advocates of natural latex rubber elastics in
Orthodontics include Baker, Case and Angle

Recent Advancements


Recently, polynorbornen, a shape memory plastic
developed in Japan in 1983 has been tried
experimentally for intra-oral usage.



This plastic has a glass transitional point of 350 C.
Once the environmental temperature exceeds the
critical point, this plastic will begin to display an elastic
property, then return to its original shape, if deformed

Fluoride releasing elastomerics :


Advances in the field of elastomerics are the
introduction of fluoride releasing elastomerics. Long
term fluoride releases in the area adjacent to bracket –
adhesive margins is of significance.



There is a steep decline in rate of fluoride ion elution
after 3 weeks.



Fluoride – releasing elastomerics are unable to deliver
force within the optimal range for tooth moment.

Elastomeric Ligatures
Preferred over S. S ligatures
 Ease of application.
 Patient friendly nature.
 Aesthetic appearance.
 Potential of fluoride release.
 Decreased force delivery.


•They are available in a range of diameters and thickness
and are often colored to encourage patient motivation.
•They are also available in various colors



The staining of clear elastomeric modules used to
ligate ceramic and tooth coloured brackets is a
problem.



The study by Kenneth K.K found that elastomeric
modules get stained by many food products, coffee
and tea being the main culprits.


Elastomeric E Link Modules


Elastomeric E link modules with connecting
filaments are excellent for rotating individual tooth or
closing intra arch space.



Stamped from highly resilient opaque white or gray
material (T.P. Lab Inc.,) they provide gentle,
continuous force over long periods of time without
breakage


Elastomeric chains :


Elastomeric chains of polyurethane nature is commonly
used to generate light continuous forces for canine
retraction, diastema closure, rotational corrections and
arch constriction



They can also be used for bringing a displaced tooth into
the line of the arch.



Available in a range of sizes which have different lengths
between the rings that fit over the brackets



This allows them to be used in a variety of clinical
situations such as moving lower incisors, where the inter
bracket distance is smaller than that used with upper
incisors and in situations where different forces are
needed in various parts of an arch



Chain elastics are thus most useful for closing small
space.

Disadvantages


When extended and exposed to oral environment, they
absorb water and saliva, permanently stain and suffer a
breakdown of internal bonds that leads to permanent
deformation.



They are also difficult to clean and tend to accumulate
food debris.



If breakage occurs, there is the possibility of unwanted
tooth movement taking place, for example, space opening
at the site of failure.



They generally lose 50-70% of their initial force during
the first day of load application and at 3 weeks, retain
only 30-40% of the original force.

Draw backs







Though elastic ligatures are used during initial aligning
and leveling, their rapid force loss and permanent
deformation may preclude use for rotational and torque
corrections
Elastomeric chains are not inert in the oral environment.
The deleterious synergistic effect of loading and water
immersion is attributed to susceptibility to hydrolysis of
the ester or ether backbone linkages in polyurethanes.
This result in reduction of required to maintain fixed
extension.
Elastomeric ligatures may be ineffective for treatment
applications involving large rotational moments.





The pH and temperature variations in the oral environment,
along with accumulation of plaque and formation of
microbial colonies on surface can affect the properties of
elastomerics.

Elastomeric modules experience a steep decline in force of
40 – 50% during first 24 hrs, which continues at a lower rate
for 2 to 3 weeks.
Force degradation arises form 2 processes in
elastomerics: Rapid mechanism i.e. responsible for the large initial
force loss.
 Relatively slow rate of force loss at longer periods of
time.

Tooth colored – ligature wires


Teflon coated Ligature







No discoloration.
The coating wears off after 2-3 weeks and the metal
is exposed.
Produces less friction when compared with
elastomeric ligatures & stainless steel ligatures.
It generates lighter forces of engagement of the arch
wire into bracket slot.


Composite ligature




Fabricated from the acrylic monomer n- butyl
methacrylate and drawn poly ethylene fibers.
Due to stress relaxation properties within an
hour it loss 98% of ligation forces( not used in
sliding mechanism).


TOOTH COLORED ALIGNING
APPLIANCES- INVISALIGN


TOOTH COLORED ALIGNING
APPLIANCES- INVISALIGN


The Invisalign system was introduced at an orthodontic
meeting in 1999 and first described in a peer-reviewed
publication in 2000.



Controversy remains over whether the system is
appropriate for moderate-to-difficult malocclusions.



Early longitudinal clinical trials demonstrated successful
use of Invisalign for tipping movements, incisor rotations,
and closure of naturally occurring spaces.

Intra oral picture of Invisalign appliance






The system is less effective in more difficult procedures
such as extraction space closure
Invisalign system (Align Technology,Santa Clara, Calif)
has become a popular treatment choice for clinicians
because of the esthetics and comfort of the removable
clear aligners compared with traditional appliances.



With the advent of 3-dimensional graphic imaging and
computer-aided design/computer-aided modeling
techniques



Align can accurately fabricate numerous aligners to
move many teeth with relative precision to provide
comprehensive orthodontic treatment.

Indications for invisalign:


Include mild to moderate crowding (1-6 mm), mild to
moderate spacing (1-6 mm), nonskeletal constricted
arches, and relapse after fixed appliance therapy

In 2003, Align Technology formed a Clinical




Advisory Board (CAB) consisting of 13 orthodontists
who had used Invisalign treatment extensively in their
practices
This group decided to adopt a new protocol already
being used by several of its members

The principles of this new protocol are as follows:






1. Simultaneous movement of all involved teeth(Similar
to the use of light archwires and low-friction brackets for
leveling and alignment) this creates the space needed for
tooth movement and slows down the movement of all
teeth except the one requiring the greatest number of
stages to be corrected at a given velocity (the
“determining tooth”)
2.Use of beveled 1mm (buccolingual
dimension)horizontal rectangular premolar attachments
for retention of aligners during intrusive movements
3.Use of 1mm vertical rectangular attachments for
rotation of round teeth or canines, as well as translation
of teeth adjacent to www.indiandentalacademy.com
an extraction site









4.Slowing down certain types of tooth
movement,including rotation, extrusion, torquing, and
bodily movement, below the previous standard velocity
of .25mm per stage
5.Maintaining visible space (approximately
.1mm)between teeth during movement of one tooth past
another.
6.Using expansion instead of interproximal reduction as a
primary method of increasing the space available for
correction of crowding.
7. Delaying any interproximal reduction that may be
needed to correct Bolton discrepancies and other toothsize issues until the teeth are aligned,to avoid removing
enamel at an angle. www.indiandentalacademy.com

A case treated with Invisalign
Pre-treatment views


Pre Treatment OPG


Post-treatment views


Post Treatment OPG


LINGUAL ORTHODONTICS




Adult patients present with unique challenge, of
wanting to look good even during orthodontic
treatment.



Some orthodontists thought of placing braces on
the lingual side, leaving the labial surface
untouched.



Thus was born the methodology of lingual
orthodontics.

History
1889 by John Farrar. "lingual removable arch"
1918, Dr. John Mershon "The Removable
Lingual Arch as an Appliance for the
Treatment of Malocclusion of the Teeth".
1922 Mershon's presentation on labial and
lingual arches with finger springs

History


March 1942 , Dr. Oren Oliver gave a clinic on
a labiolingual appliance



Mid-'50s, Dr. William Wilson demonstrated a
labio-loop-lingual appliance


History


The orthodontic company Ormco in
conjunction with Dr. Wildman, had attempted
to develop a system to align the dentition using
the lingual approach.



Consisted of a Pedicle positioner.


History
In early 1970s
Dr. Craven Kurz, an assistant
professor at UCLA school of
dentistry, developed Lingual
system.
A particular patient , because
of her public position refused
metal or plastic labial
appliance.

History


After much advice (Dr. Jim Mulick), Dr. Kurz
developed first True lingual appliance.
The turning point in the
development of the appliance
was the addition of an anterior
inclined plane as an integral
part of the maxillary incisor
brackets .

History


This inclined plane converted the shearing forces
produced by the mandibular incisors to
compressive forces applied in an intrusive and
labial direction.



It was this design that, Dr.Kurz applied on a
patent for the Kurz Lingual Appliance on
November 15, 1976.



The lingual task force pioneers Dr. Kurz,
Gorman and Smith were the first to conduct
courses on the Edgewise lingual appliance.


History


Dr. Vince Kelly of Oklahoma and
Dr. Steve Paige of Florida were the first to start
giving courses using Begg appliance lingually.



Dr. Dilier Fillon of France is the only
orthodontist to have restricted his practice to
lingual orthodontics exclusively.



Dr. Lorenzo Favero, Italy, was first to treat
children and adolescents with LO.

Lingual Brackets
Generations


First generation (1976)
Flat maxillary occlusal bite
plane from C-C
Lower incisor and
premolar bracket had low
profile and half round.
No hooks on any
bracket

Second generation (1980)



Hooks were added to
canine brackets


Third generation (1981)
Hooks are added to
all Anteriors and
Premolar brackets
The first molar had
a bracket with
internal hook
2nd molar had a
terminal sheath
with out a hook.

Fourth generation (1982-84)


Addition of low profile
anterior inclined plane



Hooks were optional


Fifth generation (1985-86)
Anterior inclined plane
became pronounced

Increase in labial
torque in maxillary
anterior region


Fifth generation (1985-86)




Canine – bibeveled
inclined plane
Attachment for TPA
provided


Sixth Generation (1987-90)
The inclined plane on the
maxillary anteriors become
more square in shape.

Hooks were elongated
and were available for all
the brackets.


Seventh generation 1990- 2002
The lower anterior
brackets have larger
inclined plane with short
hooks

Maxillary anterior inclined
plane is now heart shaped
with short hooks

Seventh generation 1990- 2002
The premolar brackets were
widened mesiodistally and
hooks were shortened the
increased width of Premolar
bracket allows better
angulation and rotation
control.


Insertion of wire


Generation–8. (2002) (STb) Giuseppe Scuzzo &
Takemoto
The STb lingual bracket
was developed to obtain
the maximum satisfaction
for the patient.

Reduced dimension
together with its special
rounded design, makes
it unique from all other
lingual brackets.

LIGHT LINGUAL PHILOSOPHY
Based on 3 fundamental points:
1. Less Lab Procedures
STb does not need a lab set-up in non
extraction cases.


2. Low Friction

A friction free system (using light wires)


Reduced treatment time.


3. Low Forces
The low force mechanics decrease stress of
the dental movements and make this appliance
reliable not only from a biomechanical but also
from a biological point of view.


ADVANTAGES
&
DISADVANTAGES


Advantages Of LO
 Esthetic role.

 Decreased plaque accumulation


Advantages:
 No permanent and unsightly decalcification
marks on lingual surface.
 Easy access for routine oral hygiene
procedures on the labial surfaces.
 Clinical judgement of treatment progress can
be enhanced.

Advantages:
 Evaluation of individual tooth position.

 Soft tissue responses of the lips and cheeks to
treatment can be judged accurately.


Disadvantages:


Discomfort to the tongue



Difficulty in speech, which usually improves
after 2-3 weeks of appliance placement


Disadvantages:
 Extended chair side time needed for appliance
placement and adjustments
 Expensive


Mechanical characteristics:
Four distinct situations exist where lingual
appliances may be more effective than labial
appliances.

Intrusion of anterior teeth
 Maxillary arch expansion
 Combining mandibular repositioning
therapy with orthodontic movements
 Distallizationwww.indiandentalacademy.commolars.
of maxillary


Intrusion of anterior teeth:
Lingual bracket positioning places the bracket closer to
centre of resistance of the tooth
than is found with labial
bracket placement


Bite plane effect : Since the appliance is bonded,
the bite plane is always present. The net effect
appears to be light, continuous, intrusive force, a
passive extrusion occurs in posterior segment.


Maxillary arch expansion :


Maxillary arch expansion :
Reasons are :
Centrifugal force type.
Shorter interbracket distance may play a
significant role in this effect.
The thickness of the brackets.

MANDIBULAR REPOSITIONING THERAPY
WITH ORTHODONTIC TOOTH MOVEMENTS



When patients have (TMD) it is often
necessary to treat in two distinct phases.




The initial phase of treatment addresses the
TMD and associated pain symptoms.



The second clinical phase of treatment
addresses changes in the occlusion as a result
of new mandibular position.


DISTALLIZATION OF MAXILLARY MOLARS


Lingual brackets are placed closer to the centre
of resistance of the tooth than labial brackets.



Molar distalization through lingual techniques
produce more bodily movement of the tooth
and less distal tipping.


DIAGNOSIS AND TREATMENT PLANNING
Diagnosis:
 Case diagnosis is conducted in a manner
similar to established procedures.


Non-growing adult patient - Additional
diagnostic input may be required from the
periodontist, restorative dentist, and
orthognathic surgeon.

Treatment planning :
1.

Periodontal Considerations

2.

TMJ Considerations

3.

Restorative Considerations


Periodontal Considerations


This is more important with lingual and adult
patients.



Short lingual clinical crowns can present a
contraindication to optimum lingual bracket
positioning.




Lingual brackets are bonded closer to the gingival
crest than their labial bracket counterparts.



The natural cleansing action of the tongue seems
to maintain the lingual appliance with less plaque
relative to the labial appliance.




More extensive restorative and prosthetic work is
naturally increased in the adult patient.



The bonding materials will adhere only to etched
enamel, other plastics, and some porcelains
(using an intermediate silane primer).




Any practicality of replacing porcelain-fused-tometal crowns or other metallic restorations with
provisional plastic crowns ?



In case of loss of several teeth, extreme tipping,
and multiple or complex bridgework, the lingual
appliance may be contraindicated.


As a rule, if the clinician believes that the
case poses multiple technical problems if
treated with a labial approach, then these
problems are magnified greatly when treated
with a lingual mode.


Lingual crown height


Lingual clinical crown heights - 30% shorter than
the available crown on the labial surfaces.



The most critical crown heights - the Mandibular
Incisors and Mandibular bicuspids


TMJ CONSIDERATIONS


Relief of joint symptoms following lingual
appliance placement.



In those cases where the health of the
temporomandibular joint complex is in
question, splint therapy and conservative
treatment approaches are recommended.


This apparently occurs due to
1. Disarticulation of posterior interferences,
2. Creation of freedom of movement of the
"locked“ mandible,
3. Changes in muscle position and length due
to different posturing of the mandible.


IDEAL LINGUAL CASES
Non Extraction:
1.
Deep bite, mild class II.
2.

Class II div 2 with retruded mandible.

3.

Cases requiring expansion.


IDEAL LINGUAL CASES
Extraction cases:
1.
Class II, Maxillary 1st bicuspid & mandibular
2nd bicuspid
2.

3.

Only Maxillary 1st bicuspids
Mild bimaxillary protrusion with four 1st
bicuspids where anchorage is not critical.

DIFFICULT LINGUAL CASES
1.

2.
3.
4.

5.

Surgical cases
Class II tendencies
Class II four 1st bicuspids extraction
Mesiofacial pattern &/or moderate
mandibular plane angle.
Cases with multiple restorative work.


CASES CONTRAINDICATED
FOR LINGUALTHERAPY
1.
2.
3.
4.
5.

Acute TMJD
Mutilated posterior occlusion
High angle / Dolichofacial pattern
Extensive anterior prosthesis
Short clinical crown


CASES CONTRAINDICATED
FOR LINGUALTHERAPY
6.
7.
8.

9.

Critical anchorage cases.
Severe class II discrepancies
Poor oral hygiene or unresolved periodontal
problems
Unadaptable or demanding patients


KEYS TO SUCCESSFUL LO
Key-1
A. Patient Selection


Lingual patients must be well educated in oral
hygiene and motivated from the beginning.



Poor oral hygiene, particularly when coupled
with short clinical crowns, should be excluded.


B. Speech Adaptation and Tongue Irritation

 A common complaint of lingual patients is
temporary speech alteration.

 The "s", "sh", "t-d", and "th" sounds are slightly
distorted less than 10 percent of the time with
lingual appliances.

 From one to nine months after appliance
placement, there is a clinically insignificant
residual distortion of sounds.

Key 2
Bracket Placement Accuracy

Accurate placement exceedingly difficult with a
lingual appliance due to
1.

2.
3.
4.
5.

Arch radius
Interbracket distance
Compound lingual geometry
Highly variable tooth morphology and
Limited access and visibility

Key 3
Indirect Bonding:


The Advanced techniques.


Key 4
Double Over Ties on Anterior Teeth:


Conventional ligation does not exert a proper
parallel force vector with the amount of force
required to seat or adequately hold the archwire
in anterior lingual brackets.



Double-over ties are imperative to correct
rotations, achieve and maintain torque, and retract
teeth. The ties are removed with a Hu-Friedy
U15-30 scaler. www.indiandentalacademy.com

Metal over-ties


Elastic over-ties


Key 5
Buccal and Lingual Molar Attachments
Set the band as occlusally
as possible on the lingual
surface.

Any lingual molar attachment
should then be welded flush
with the occlusal edge of the
band.

Buccal and Lingual Molar Attachments


In extraction cases, the first molar attachment
should be tipped mesiogingivally about 6° to
help parallel the roots


Key 6
Correcting Rotations


With labial brackets, teeth usually rotate out to
the labial to a greater arch radius, thus providing
the necessary space to correct the rotations.



With lingual brackets, the reverse occurs and the
teeth are brought into a more constricted arch
radius.

Correcting Rotations


Failure to adequately seat the archwire in the
base of the slot can cause rotation problems.
These can be avoided by using the double-over
ligation technique


Key 7
Arch Form and Archwire Sequence


Natural variations in facial-lingual tooth
dimensions are common on the lingual aspect.


Wire sequencing :


First initial wires 0.016 NiTi.



Second initial wires 0.016 special plus (wilcock)
heat treated stainless steel.



Intermediate wires 0.017 x 0.025 TMA.


Wire sequencing:


Finishing wires 0.017 x 0.025 or 0.016 x 0.022
SS.



Detailing wires : Wilcocks (Australian) 0.016
or 0.018 special plus. This sequence is
followed for all cases class I, II, III.


Key 8:
Archwire Stiffness and Torque Control


Retraction of teeth into extraction sites and
correction of anteroposterior discrepancies
require a significant amount of force.



Partial retraction of cuspids - .016"



En masse retraction of the anterior segment .016" .022"

.016" SS

If retraction is attempted on lighter wires, significant
adverse changes may occur, including:
1. Excessive tipping into extraction sites .
2. Loss of torque control
3. Molar rotation
4. Buccal crossbite
5. Lateral outward bowing at the extraction site .




D-RECT wire has sufficient resiliency and
torque control to reverse some unwanted
changes.



.0175" .0175" TMA excellent for
establishing early torque control.



.016" .022" SS archwire provides adequate
torque control.


Key 9 :
Enmasse retraction

Enmasse retraction not only requires fewer
wire changes but it eliminates the
disadvantages of two stage retraction.

1.
2.

It can be achieved by
Loop mechanics
Sliding mechanics

Key 10
Light, Resilient Wire for Detailing


Detailing done with a light, round wire such as
.016" TMA or stainless steel.



A tie-back or bend-back distal to the second
molars will help prevent spaces from reopening.
Vertical elastics and artistic bends are used to
obtain a final occlusion.

Lingual bracket jig


References














Orthodontic materials -William A Brantley
Current principles & techniques-Graber ,Vanarsdall
Plastic Brackets-Schwartz AJODO 1971 July
Shear bond strength of Plastic brackets-Guoqiang Guan AJODO
2000
Stress analysis of plastic bracket configurations-Michael D Rains
A history of Braces
Bond strength and debonding characteristics of a new ceramic
bracket-Jia Kuang Liu
Comparative evaluation of ceramic bracket base designs-Joseph
M Bordeaux
Lingual Orthodontics – Rafi Romano, DMD,MSc

References












Clinical characteristics and properties of ceramic brackets: A
comprehensive review- Andreas Karamouzos AJODO1998
Clinical management of ceramic brackets- Richard N Carter,
AJODO1998Apr
A comparsion of shear bond strengths of metal and ceramic
brackets-A John Gwinnett
Clinical characteristics and properties of ceramic brackets: A
comprehensive review- Andreas Karamouzos AJODO1998
Clinical management of ceramic brackets- Richard N Carter,
AJODO1998Apr
A comparsion of shear bond strengths of metal and ceramic
brackets-A John Gwinnett

References








Complex Orthodontic Treatment Using a New Protocol for the
Invisalign Appliance ROBERT L. BOYD, DDS, MED-JCO
VOLUME XLI NUMBER 9; 525
Orthodontic Biomaterials: From the Past to the Present
Robert P. Kusy, PhD-Angle Orthodontist, Vol 72, No 6, 2002
Outcome assessment of Invisalign and traditional orthodontic
treatment compared with the American Board of Orthodontics
objective grading system-Garret Djeu, Clarence Shelton, and
Anthony Maganzin-(Am J Orthod Dentofacial Orthop
2005;128:292-8)
Esthetic Orthodontic Treatment Using the Invisalign Appliance
for Moderate to Complex Malocclusions-Robert L. Boyd, D.D.S.,
M.Ed.-Journal of Dental Education ■ Volume 72, Number 8; 948

Thank you
Leader in continuing dental education


Esthetic orthodontic applainces /certified fixed orthodontic courses by Indian dental academy

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