How to gain space in orthodentics

1. EXTRACTION OF TEETH AS
PART OF ORTHODONTICS
• prepared by : Mohammed Farag & Yaser Basheer
Lecture by : Prof. Dr Maher Fouda
dr_maherfouda@yahoo.com

2. Methods of gaining space in the
permanent dentition
Common methods of gaining space
1) Arch expansion
2) Inter-proximal reduction
3) Molar distalization
4) Selective/ therapeutic extractions

3. The upper arch is
well suited for
expansion than its
lower counterpart.
Usually done in
narrow contracted
upper arches with
cross bites in the
premolar region.
Arch expansion

4. Arch expansion devices
Hyrax expanderQuad helix
Haas expanderJackscrew
Beidner type.NiTi expander
W arch

5. Hyrax expander

6. •arch expansion by
quad helix

8. Oclusal view before treatment
Beggining of Treatment

9. After 4 months
After 2 months.

10. Before and After Quad-Helix– 5 months total time

11. GAINING SPACE BY INTERPROXIMAL REDUCTION
• Interproximal reduction is a procedure to create space for
crowding and increase stability by flattening curved contact
surfaces.
• The enamel is removed by using either:
• a fine dental bur
• a disc in a dental handpiece (drill) or
• by hand with an abrasive strip

12. Enamel reduction by dental bur
Enamel reduction by hand using a abrasivestrip
Diamond Strip
Abrasive Disc

15. maximum of 0.5 mm interproximal reduction
per contact is recommended. Therefore, a total of
2.5 mm of tooth-size reduction is possible from
cuspid to cuspid

16. • Decision to do interproximal reduction is based on the
model analysis concerning the overall size
discrepancy.
• It could also be added up with a Bolton analysis

19. GAINING SPACE BY MOLAR DISTALIZATION
• An 11-year-old girl was referred to our clinic for
orthodontic treatment with a chief complaint of
protruding upper anterior teeth and irregular
upper and lower
• With class1 divission 1 mallocclusion

20. Facial and intraoral photographs of the case before treatment (age 11 years)

21. Pretreatment lateral cephalometric and panoramic radiographs of the case

22. TREATMENT OBJECTIVES
• The treatment objectives, based on the clinical examination and the
cephalometric analysis, were to
• 1. Distalize the maxillary molars to establish a well-intercuspated bilateral
Class I molar and canine relationship.
• 2. Retract the upper incisors for overjet reduction.
• 3. Ideally align the fully erupted lower and upper permanent teeth.

23. Occlusal views of the Frog Appliance. A, During activation; B, on
the dental cast and immediately after the cementation

24. Upper occlusal view of the patient immediately after the distalization (A), and intraoral photographs after
cutting of the anchor wires of premolars (B-D) (after 4 months of distalization)

25. Lateral cephalometric and panoramic radiographs of the case
taken immediately after the distalization

26. Facial and intraoral photographs of the case at the end of the fixed orthodontic treatment (age 12
years 4 months).

27. EXTRACTION

39. post treatment
Pre treatment

40. As this case illustrates, it may be advantageous to
remove second molars instead of premolars in
selected patients who cannot be adequately
treated without extractions. Second molar
extraction can create sufficient space in the
posterior segments of patients with crowded
arches, providing good long-term facial and dental
esthetics. In addition, it is a relatively simple
procedure that leaves the patient with the
maximum possible number of permanent teeth.

48. 11 year old female patient Class II canine and molar
relation "".
She has a 7mm overjet, a deep bite and5mm tooth-
size arch-length discrepancy in the upper arch.
The treatment objectives were to align teeth,
reduce overjet, achieve aclass I canine relation and
accept a class II molar relation.

52. Active tiebacks were continued.
The patient missed two appointments, shecame
back with and edge to edge occlusion .
"Arches werere moved to allow the arches to
relapse

53. Closing the remaining extraction space came from
burning anchorage and moving upper molars mesially.
Case finished with aclass II molar relation, which was
anticipated.

56. The dental panoramic tomogram confirmed the
presence of all permanent teeth, including
developing third molars.
The first molars were all restored or carious, and
their long-term prognosis was considered to be poor.

64. Twelve months into treatment, left maxillary lateral
incisor (22) was included for alignment

66. Fifteen months into treatment, in the lower arch a 0.016
inch stainless steel archwire was used for further
alignment and to start closing spaces

67. Eighteen months into treatment, upper and lower 0.019
inch × 0.025 inch stainless steel archwires were.
Used for arch coordination and space closure.

68. Twenty-seven months into treatment, the case was
debonded, the teeth were in well-interdigitated
occlusion.

71. The side profile X-ray and cephalometric tracing showed:
Incisor uprighting (1-NA = 0°); Class II skeletal pattern,
ANB angle = 5, (SNA = 80° and SNB = 75) and normal
mandibular growth in the vertical orientation (SN-GoGn =
32°, FMA = 23 and Y-axis = 60°).

77. The cephalometric analysis showed protrusion in the
maxilla and mandible in relation to the cranial base,
skeletal Class I malocclusion, dolichofacial pattern,
protruding upperand lower incisors with increased axial
inclination Normal bone profile, straight facial profile.

93. • The patient had already extracted his four first
premolars hoping that this would alleviate mild
crowding present this had only lead to deep bite
and four extraction spaces

102. • The four first premolars had already been
extracted notice canted maxillary occlusal plane
excessive gingival display

105. Cephalometric analysis revealed a retrusive mandible
(ANB angle 7°) and an increased IMPA angle (94°). The
SNA angle was within the normal limits (82º); however,
SNB angle was decreased (75º). In other words, patient
had a skeletal class II profile accompanied with
mandibular dental compensation.

114. Mandibular incisor extraction can be an effective treatment
option in border line cases with mild crowding in lower arch. In
patients with moderate crowding and without excessive
mandibular tooth mass, interproximal reduction may be a better
alternative. Formation of open gingival embrasures or black
triangles is a common side effect of mandibular incisor
extraction. Minimal alteration of mandibular arch form is key for
success and stable results.

123. • a 15-year-old boy who had an Angle Class I malocclusion
with a right palatally impacted maxillary canine. The right
deciduous canine was also persisted in the mouth. The
treatment involved the tunnel traction method, by which the
impacted canine was pulled toward the center of the
alveolar ridge via the deciduous canine socket.

124. PRETREATMENT INTRA ORAL PHOTOGRAPHS

125. PRETREATMENT PANORAMIC RADIOGRAPH

126. PRETREATMENT OCCLUSAL RADIOGRAPH

127. Intra oral lateral photograph Occlusal photograph

128. OCCLUSAL RADIOGRAPH

129. PANORAMIC RADIOGRAPH

130. DURING DIRECTED TRACTION:
CANINE INTO ITS PROPER POSITION

131. POST TREATMENT INTRAORAL
PHOTOGRAPHS

132. POST TREATMENT INTRAORAL
PHOTOGRAPHS

133. RADIOGRAPHICALLY, THE RIGHT CANINE DISPLAYED
PROPER ROOT INCLINATION AND THE INCISORS
REMAINED STABLE AT THE END OF TREATMENT

134. POST TREATMENT PERIAPICAL
RADIOGRAPHS

135. .

136. Pretreatment extraoral and intraoral photographs

137. Transpalatal bar for maintaining arch form, partial canine retraction, and uprighting intrusion
force on mandibular posterior teeth

138. En masse retraction of 6 maxillary anterior teeth with Ni-Ti coil springs connected
from microscrew implants

139. Application of intrusion force on maxillary and mandibular posterior teeth.

140. Post treatment extraoral and intraoral photographs

141. THANX