Orthodontic alignment phase of pre-adjusted fixed appliance part 2
- 1. Orthodontic alignment phase of pre-adjusted fixed appliance part 2 Prof dr Maher fouda Mansoura Egypt
- 2. No single arch form is unique to any of the Angle’s class of malocclusion but it is the frequency of a particular arch form that varies among Angle’s classification groups.
- 3. Arch Form For over a century, there has been a persistent search for the ideal arch form for human dentition. Changes to arch form during treatment may result in instability and subsequent relapse, which can contradict this search for the ideal arch form.
- 4. Arch Form There is an awareness that a great deal of variation exists from one human arch form to another. With this in mind, 3M provides three distinct arch forms that reconcile the variation in anterior curvature, inter-cuspid width, inter- molar width and the curvature from the cuspid to the second molars.
- 5. Treatment should be directed toward maintaining the arch form presented by the malocclusion as much as possible. Arch Form, Particularly the Mandibular Arch, Cannot Be Permanently Altered with Appliance Therapy (a) Pretreatment mandibular occlusal view. (b) Five months: driftodontics. (c) Ten months. Second archwire: 0.016 × 0.022- inch SS closing loops. (d) Twelve months. Third archwire: 0.017 × 0.025-inch SS finishing. Second molars banded.
- 6. In a clinical situation, orthodontists should select the most appropriate archwire for the patient arch form and treatment plan to align and level the teeth. This step is sometimes neglected as the orthodontists might assume that light NiTi archwires will not alter archwidth. Maxillary archforms. (A) Narrow. (B) Ovoid. (C) Square Selecting the archwire on the pretreatment model
- 7. Preserving the arch form also affects stability of the treatment results. The intercanine width of each patient is determined by muscular balance, and any unintended expansion in this region could cause instability 1: intermolar width; 2: intercanine width; 3: molar depth; 4: canine depth.
- 8. It is generally advised to maintain the patient arch form during fixed orthodontic treatment. Orthodontic archwires play a significant role in expansion of the dental arch. The determination of arch form with software analyze
- 9. This is more important during the use of nickel titanium (NiTi) archwires, as these wires are not easily customizable and may contribute to arch form development during early stages of treatment. Different arch forms of cases of malocclusion
- 10. Pre- formed NiTi archwires are available in various shapes and sizes, and their average intercanine width could exceed the natural mandibular intercanine width by almost 6 mm. NiTi arch wire used for alignment and leveling.
- 11. Thus, it is important to select prefabri- cated NiTi archwires that are similar to the patient arch form to minimize changes and reduce possible relapse. Template with maxillary and mandibular arch forms
- 12. The therapeutic arch form should be de- signed by considering the original arch form of the patient and treatment objectives. Ricketts pentamorphic arch form template
- 13. Most orthodontists selected archwires subjectively by visual assessment of the adaptation of the archwires to the facial axis or facial surface of the teeth, incisal edges and cusp tips, or the facial portion of the proximal contacts. Contoured nickel- titanium arch superimposed on a model. G&H STANDARD FORM ARCHFORM CLEAR TEMPLATES
- 15. Archform analysis The maxillary arch width in the premolar and molar regions should be assessed to determine, if it is narrow, normal or broad. These values depend on the combined mesiodistal widths of the four upper incisors (SI).
- 16. Archform analysis The values thus obtained indicate the ideal values of premolar and molar widths. The actual measured values of the interpremolar (mesial occlusal pit of first premolars on either side) and intermolar (mesial occlusal pit of first molar on either side) widths are compared to the ideal values to conclude whether the arch is narrow, normal or broad.
- 17. Nitinol Heat-Activated is a thermally activated super-elastic archwire. It is the easiest of Nitinol wires to engage, and it delivers light continuous forces that effectively move teeth with minimal discomfort to the patient. Archwires that are used during the first phase of alignment of teeth
- 18. Nitinol Heat-Activated • Can be cooled or chilled resulting in a softer, more pliable wire for easy engagement • Provides light continuous forces • Force activation occurs around body temperature • Available in square sizes making it excellent for early torque control
- 19. Unitek™ Nitinol Super- Elastic Archwire Nitinol Super- Elastic is easy to engage and maintains light continuous forces with a range between Nitinol Heat-Activated and Nitinol Classic. *Hybrid **Dimpled Nickel Titanium Dimpled ArchWire
- 20. Unitek™ Nitinol Super- Elastic Archwire • Provides light continuous forces • Easy engagement characteristics • Good early torque control
- 21. Superelastic NiTi 0.014- inch during initial alignment orthodontic stage, before and after bracket engagement. Note the degree of misalignment that the wire can tolerate due to superelastic properties.
- 22. Unitek™ Nitinol Classic Archwire 3M pioneered nickel- titanium as an improved alternative to stainless steel in 1977. DuraForm® NiTi Dimpled Archwires
- 23. • Long working range • 40% the forces of stainless steel This “Classic” archwire continues to provide the linear elasticity and bendability of high strength steel and the elastic working range and lighter forces that only a nickeltitanium can deliver.
- 24. wire progression for improved efficiency in your treatment plans.
- 25. Multi-Strand Archwire Unitek™ Coaxial Wire • Five (5) tempered wires wrapped around a core wire • Light force • Highly flexible – easy to engage • Excellent initial wire • One form for both U/L arches • Ends do not unravel when cut
- 26. There is evidence showing that multi- stranded superelastic NiTi wires can produce greater tooth movement than single-strand superelastic NiTi when used as the first archwire in a fixed (“train track”) brace. Pearson ® 6-strand Coaxial Archwire - Standard Excellent for initial leveling and aligning when teeth are severely misaligned. Great flexibility and super smooth silky finish means less resistance and lower friction when engaged in bracket slot!
- 27. The use of multi- strand stainless steel vs superelastic NiTi does not have a noticeable difference in the pain experienced by the wearer. Morelli Orthodontic Wire Twist Flex (3 strand)
- 28. Due to the gentle nature of the wire, round stranded wires are traditionally used in early treatment to correct misaligned teeth. Stranded wires apply a low force level over a given span with minor to moderate deformation depending on the severity of the malocclusion. The wire is flat and is excellent for the fabrication of Lingual Retainers
- 29. Rectangular stranded wires are typically used in transitional applications to align and detail occlusions effectively with comparatively lower force than solid stainless steel archwires TruForce Stainless Steel 8-Strand Braided Archwire •Stable for finishing and holding •Type 304 stainless steelSmooth bright finish •Does not unravel when cut •Etched midline
- 30. Unitek™ Stainless Steel Straight Lengths By 1950s stainless steel alloys were used for most orthodontic wires • The most popular wires because: E Low cost E Excellent formability E Can be soldered and welded
- 31. Tooth-Colored Nickel Titanium Archwires • Durable epoxy coating • Stain resistant • Midline marked • Available in stainless steel Tooth-colored archwires are ink midline-marked (black upper, red lower) for symmetrical identification. A cotton swab dipped in isopropyl alcohol will remove the majority of the ink after placement if desired.
- 32. Bioforce Arch wires • It produces a gradient of force levels • It applies gentle and low forces to the anterior teeth • It applies increasingly higher forces across the posterior and plateauing at the molars
- 33. In contemporary treatment, overbite reduction is increasingly undertaken in tandem with alignment. Treatment sequence was performed with sequence of rounds archwires (both NiTi and stainless steel) until 0.020’’ stainless steel with reverse and accentuated curve of Spee 2017 Contemporary Clinical Dentistry
- 34. Initial orthodontic alignment requires high degrees of wire flexibility permitting engagement of grossly displaced and irregular teeth, particularly with limited inter-bracket span in the lower anterior region and in areas of significant crowding.
- 35. Firstly, a fixed tongue crib appliance was given to the patient for six months . After 6 months, the case was strapped up with 0.022 slot brackets of MBT prescription. Maxillary left upper first premolar was extracted. Both arches were bracketed, and the wire was placed in the sequence of 0.016 Nickel-Titanium super elastic round wires for the alignment of the teeth followed by 0.018 stainless steel wire. Non Surgical Management of a Mutilated Skeletal Class II Malocclusion with an Open Bite: A Case Report Int J Dent Med Res | MAR- APR 2015 | VOL 1 | ISSUE 6 Case report
- 36. Pre-treatment extraoral and intraoral photographs Non Surgical Management of a Mutilated Skeletal Class II Malocclusion with an Open Bite: A Case Report Case report
- 37. During the leveling and aligning stage, a vertical holding appliance consisting of an acrylic button in the trans-palatal arch was given in the maxillary molars to control the extrusion of the maxillary molars. The round wires were followed by 0.019x.0.025 stainless steel wires for initial torque control and better alignment. Then the cantilever mechanics were used on the left side of the maxillary incisors to shift the midline to the left side. Case report
- 38. Case report
- 39. A segmental 0.019 x 0.025 stainless steel was placed in the maxillary incisors during use of segmental cantilever mechanics. After the correction of the maxillary dental midline, a 0.018 stainless steel wire with vertical helices was placed, and simultaneous Class II elastics were given for the closure of the spaces in the maxillary arch. After 16 months of treatment, the extraction spaces were closed, maxillary dental midline was corrected, proper overjet and overbite were established. The finishing and detailing took another 2 months. Case report
- 40. Non Surgical Management of a Mutilated Skeletal Class II Malocclusion with an Open Bite: A Case Report Case report
- 41. Alignment and levelling of maxillary and mandibular arches before the initiation of retraction mechanics. Case report
- 42. Alignment is usually undertaken over a period of approximately 6 months pending on the pre-existing space conditions and involves progression from low-dimension round (0.012- or 0.014-in.) Nickel- Titanium (NiTi) to larger dimension round (0.016-, 0.018- and 0.020-in.) and square or rectangular (0.020 × 0.020-, 0.017 × 0.025-, 0.018 × 0.025- and 0.019 × 0.025-in.) NiTi wires. Case report
- 43. Archwires may be held in place using elastomerics, stainless steel ligatures or inbuilt mechanisms with self-ligating systems.
- 44. Conventional modes of ligation, however, are limited in relation to efficiency of handling, plastic deformation, discoloration, plaque accumulation and friction.
- 45. Self-ligating brackets have been developed in an attempt to address these shortcomings.
- 46. Stainless steel ligatures may also be used in areas of significant rotation or displacement and when active mechanics are in use to promote rotational correction during alignment and indeed to limit unwanted rotations during sliding mechanics and space closure.
- 47. Initial Wire Placement and Engagement: Practical Steps The wire is initially cut to length with distal end cutters using the study model as a reference and centred using a midline indicator . Distal end cutter A midline identifier (circled) on an upper 0.014-inch NiTi wire
- 48. A small distal excess (3–7 mm) is advisable to allow for wire cinching and possibly for additional length in order to compensate for wire deflection with engagement of displaced and crowded teeth.
- 49. Round wires are introduced using fingers to thread into the molar tubes initially. An initial alignment NiTi wire inserted through the molar tubes using fingers only. A Weingarts may be helpful in the presence of significantly rotated molars or with larger dimension wires
- 50. A pliers (e.g. Weingarts) may be used to direct this but is often not required for narrow dimension wires. Ricketts pantamor- phic arch form templates, ovoid, tapered (V-shaped), and square (U-shaped) forms
- 51. A mosquito forceps is used with the tips enclosing one edge of the elastomeric while leaving the lumen exposed permitting a secure grip and engagement of the undercuts of tie- wings. A range of elastomerics. (a) The beaks of the mosquito forceps should not encroach on the central lumen (b) to allow positive engagement of bracket undercuts
- 52. Ligation may be commenced in the anterior region to stabilise the wire initially. Ormolasts are typically used engaging all four tie-wings sequentially in an O- configuration. (a–e) Sequential placement of an ormolast in an ‘O’- configuration on the maxillary central incisor
- 53. It is advisable to engage a gingival tie-wing initially before proceeding to both occlusal tie- wings and finally the remaining gingival wing. (a–e) Sequential placement of an ormolast in an ‘O’- configuration on the maxillary central incisor
- 54. Ligature Tucker
- 55. Partial ligation, figure-of-eight ties and use of stainless steel ties can be considered with more displaced or rotated teeth. (a–h) Placement of an ormolast in a figure-of-eight configuration following initial prestretching
- 56. Partial ligation, figure-of-eight ties
- 57. Care is taken to tie and cut the ligature at right angles to the attachment to avoid introduction of shear forces which might predispose to attachment failure Placement of a stainless steel ligature.
- 58. Placement of a stainless steel ligature.
- 59. Pre-stretching of elastomeric makes the ormolast slightly more lax permitting the degree of stretch required to allow figure-of- eight formation.
- 60. Chang suggested 100% prestretching in clinical applications to reduce the initial force. Some studies have recommended prestretching orthodontic synthetic elastomeric chains before use. Wong found in his studies that elastomeric materials should be pre-stretched one third of their length to stress the molecular polymer chain, thus increasing the strength of the material.
- 62. Pre-stretching of elastomeric makes the ormolast slightly more lax permitting the degree of stretch required to allow figure- of-eight formation.
- 63. Partial ligation is likely to inhibit progression to a significantly larger wire at the subsequent visit.
- 64. More complete ligation, however, promotes better alignment of the slots and therefore wire progression.
- 65. This is, however, not always realistic in view of the degree of displacement or rotation.
- 66. Stainless steel ligatures offer potential advantages with lower resistance to sliding than elastomerics and less force decay making wire ligation more assured.
- 68. A B
- 69. Metal ties may also be used in areas of significant wire displacement. It is helpful to bend the ligature at approx. 90° to assist with placement .
- 70. The ligatures should ideally be tied at 90° to the plane of the bracket as shear forces on the bracket risk debonding during tightening.
- 71. Similarly, the ligature cutters can be held parallel to the bracket with a wire tail of approx. 3 mm, which can be tucked occlusally with a wire tucker in order to promote optimal gingival health .
- 72. Firm ligation is advised when stainless steel ligatures are used;
- 73. It is important, however, that these are not over- tightened as this risks irreversible surface change to the archwire including notching, which may in turn inhibit tooth movement.
- 74. An initial 0.014- in. NiTi wire has been ligated in this arch with significant palatal displacement of the maxillary right lateral incisor. Engagement of a displaced maxillary lateral incisor. In this instance, there is sufficient space to align the lateral incisor
- 75. For ease of ligation, the most displaced tooth (UR2) is ligated initially . as such, sliding mechanics would be unnecessary
- 76. This tooth can be included in the appliance at this stage as there is adequate space to allow for alignment. Where inadequate space exists, sliding mechanics and space redistribution are advisable. All teeth have been ligated fully in this case.
- 77. Partial ligation can be considered where excessive wire deflection occurs as this risks excessive forces and attachment debonding. Moreover, excessive deformation may lead to the superelastic properties of the wire being exceeded.
- 78. Lacebacks have been placed bilaterally from canine to first molar . Placement of a laceback ligature
- 81. It is helpful to tie the wire off after initial engagement of the molar hook .
- 82. Tie-wings of premolar and canine brackets should be engaged positively to ensure the laceback is secure .
- 83. At subsequent visits, lacebacks are likely to become lax as the canines move distally and molars in a mesial direction.
- 84. The laceback may be left in place, while the arch wire is removed and can be activated simply by twisting the wire with an explorer tip . Reactivation of a laceback using an explorer tip. This does not necessitate removal and replacement of the wire
- 85. Lacebacks are fabricated from 0.09″ to 0.10″ stainless steel wire spanning the first molars to canines.
- 86. They represent a means of controlling the anteroposterior position of the incisors during the initial alignment phase by limiting forward movement of the canine crowns while the mesial tip prescription of the canine teeth is expressed.
- 87. Lacebacks are of potential value in extraction cases or spaced arches.
- 88. Orthodontic extractions may promote more stable relief of crowding by generating space to limit or avoid unwanted advancement of the anterior segments. Lace-backs for distal movement of canines following extraction of first premolars.
- 89. The mesial angulation in-built in canine brackets predisposes to forward movement of the incisors in conjunction with alleviation of crowding during the initial alignment phase. Andrews/Roth/MBT tip values
- 90. While the incisors may be moved posteriorly later in treatment, particularly during space closure, reciprocal movement of this nature (‘round tripping’) is considered undesirable predisposing to root resorption, periodontal attachment loss and more prolonged treatment. Leveling and alignment phase
- 91. Lacebacks may be particularly useful where the canines are upright or distally angulated at the outset, A crowded Class I malocclusion with buccally displaced maxillary left canine with an associated midline shift to the left side (a–d). An initial 0.014-in. NiTi aligning wire was placed with lacebacks from canine to first molar (e–h). These assisted in achieving alignment with some distal movement of the canines (i–k) prior to definitive space closure in rectangular stainless steel wires
- 92. as in these cases, significant mesial crown movement is likely to be accompanied by advancement of the incisors. Lacebacks not only inhibit forward canine movement, but they are an effective way of distalizing the canines. This occurs because the lacebacks tip the canines at the gingival aspect of the alveolar crest.
- 93. Canine retraction: In extraction patients, the canines were retracted on round wires using elastic chains.
- 94. Canine retraction: Without the overcorrection of additional gable bends, teeth tended to tip and rotate into the extraction sites when the chains were overstretched, with associated bite deepening . the 'roller coaster' effect developing in an early treatment w i t h the original SWA. The unwanted deepening of the overbite was due t o excess force and the use of elastic retraction mechanics.
- 95. The gable or V-Bend intrusion mechanics had been known in literature, long time ago. Bendistal and Omni Pliers only could insert V-bend in super elastic wires and employed their light and consistent forces to simplify teeth intrusion for the first time. The V-Bend Mechanics On Niti Wires
- 96. V-BENDS OF BENDISTAL AND OMNI PLIERS in NiTi archwires, allow applying their light forces systems in vertical direction that simplify teeth intrusion, and easily correct the most challenging malocclusions.
- 97. A: illustrates mandibular dental arches after alignment, with the preformed NiTi archwire (in black) tied in place. The blue colored line shows the shape of the wires after receiving the permanent inverted V-bend behind the canines. B: Shows the activated tied in NiTi archwire (in light green) being tied after it intrudes the most distant anterior and posterior teeth. C: Shows the mechanical effects on mandibular dental arch before and after illustrations superimposed
- 98. Lacebacks are effective because they don't produce continual forces. The space is created, then they stop working until they are re- activated. This light, intermittent force is probably the reason the molars are unaffected. Also, the heavier forces produced by chain will cause teeth to tip into the extraction sites. Lacebacks do not cause this worsening of the malocclusion
- 99. Teeth tended to tip and rotate into the extraction sites when the chains were overstretched, with associated bite deepening. This was frequently seen and became known as the “roller coaster” effect.
- 100. Lacebacks are placed in a passive configuration and are typically intermittently activated during occlusal contact. Passive figure-eight ligature wires, called “lace- backs,” were placed from the first molars to the canines before archwire placement. It was important to avoid overtightening them
- 101. While many clinicians routinely use lacebacks to control incisor position during orthodontic alignment, they have not met with universal approval. Canine retraction with Active laceback ligature
- 102. Disadvantages of laceback use may include loss of anchorage posteriorly manifesting as mesial migration and tipping of first permanent molars, potential for plaque stagnation and limited additional chairside time and complexity. Passive figure-eight ligature wires, called “lacebacks,” were placed from the first molars to the canines before archwire placement. It was important to avoid overtightening them
- 103. Moreover, clinical trials have confirmed that control of incisor position comes at the expense of anchorage loss in the molar region (Irvine et al. 2004). As such, they remain useful in terms of alignment but are unlikely to alter the anchorage balance appreciably. With lacebacks, the periodontal space was compressed with minor tipping. The archwire was then placed and had adequate time (4-6 weeks) to upright the roots. The lacebacks were adjusted at 4- to 6-week intervals to take up any slack. 0.014" NiTi SE arch and laceback to guide distally the canines during crowding res olution. In this phase the friction occurs especially in the area of the anterior teeth.
- 104. Duration of Alignment The initial alignment phase typically spans up to 6 months but may obviously be more prolonged in cases with severe rotations, crowding and tooth displacements. (a–e) A crowded lower arch (a). A decision was made to treat this without extraction allowing advancement of the mandibular incisors. The initial aligning wires were not cinched to allow for arch lengthening. The attachments on the rotated LL3 and LL5 were not fully ligated in 0.014-in. NiTi (b); this wire was therefore retied before progressing to rectangular NiTi with complete wire engagement (c). The mandibular second molars were subsequently bonded (d), and ultimately complete alignment is achieved (e)
- 105. The latter, in particular, may necessitate extractions and sliding mechanics with space redistribution prior to inclusion of all anterior teeth within the appliance. During initial alignment, .014" and .016" round nickel titanium archwires were inserted into the −25° tipback tubes . Distal canine movement occurred without laceback ties, and initial upper alignment was achieved in six months . Only minor upper-molar tipback was observed.
- 106. Numerous studies investigating the effect of wire and bracket type on the duration of alignment have been undertaken, with less than 8 months usually required prior to engagement of 0.019 × 0.025-in. stainless steel wires in extraction cases (Scott et al. 2008). The complex force systems resulting from the severely angulated mandibular left first premolar, even with a light Ni-Ti continuous archwire, is demonstrated clinically by the adverse changes in tooth positions.
- 107. Little difference has been observed in terms of alignment efficiency with competing wires (Pandis et al. 2009) or bracket designs (Scott et al. 2008). Notwithstanding this, NiTi alloys tend to be preferred to stainless steel alternatives (including multistrand and multiloop designs, which incorporate increased wire length to enhance flexibility) in view of simplicity and resistance to permanent deformation.
- 108. Edgewise 0.022 x 0.028-in orthodontic brack- ets were placed in the maxillary arch, except for teeth #11 and 22 (maloccluded). Treatment be - gan with Twist-flex 0.015-in steel archwire placed for initial alignment and leveling. Subsequently, 0.012, 0.014, 0.016 and 0.018-in stainless steel arch- wires were progressively installed every 30 days, with omega loops mesially adjusted to the first molars. Case report
- 109. The omega loops were adjusted in 0.05 mm on each side on every orthodontic visit, increasing arch cir - cumference and length, and, as a result, establishing mild and continuous protrusion of incisors with ex- pansion of the arches. Case report
- 110. Once the 0.018-in steel wire had been installed, open springs were compressed between teeth #11 and 22 to create space between them. At this point, orthodontic appliance was installed on these teeth Case report
- 111. the 0.018” arch and the bonded appliances. At this stage, maxillary incisors were slightly protruded, thus providing enough space to correct the maloc- clusion . By the time the 0.020” stainless steel wire was installed, the incisors had been satisfactory protruded, thus providing enough mesiodistal space for buccal inclination of #11 and #22 . Buccal traction of maloccluded teeth was per- formed with mild-force elastomeric chains between Case report
- 112. After maloccluded teeth were corrected, the appliances of #11 e #22 were replaced and a new 0.014” stainless steel wire was installed for teeth alignment and leveling. Subsequently, 0.016, 0.018, 0.020-in and 0.019 x 0.025-in stainless steel wires were progressively installed for individual torque control and treatment finishing. Case report
- 113. The maxillary and mandibular teeth were bonded with 0,022-inch MBT brackets (Ortho Technology). The treatment was started using 0.012, 0.014, 0.016, 0.016 x 0.016, and 0.016 x 0.022 NiTi in both arches. After leveling and aligning were done, the next treatment was enamel stripping in central and lateral upper incisor. Space closing was done with power chain and stainless steel wire 0.016 x 0.022. Finishing and detailing were used stainless steel wire 0.016 x 0.022 and 0.017 x 0.025 both arches with elastic. Case report
- 114. Orthodontic tooth movement is initiated with 0.022 slot MBT bracket system in both the arches. 0.016 NiTi was the initial wire, followed 0.017 × 0.025 NiTi, 0.019 × 0.025 NiTi, 0.019 × 0.025 SS. In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction. In the mandibular arch, en masse retraction was carried out. Case report
- 115. Complete bonding & banding in both maxillary and mandibular arch was done, using MBT0.022X0.028”slot. Initially a 0.012” NiTi wire was used which was followed by 0.014 , 0.016”, 0.018”, 0.020” Niti archwires following sequence A of MBT. After 6 months of alignment and leveling NiTi round wires were discontinued. Retraction and closure of existing spaces was then started by use of 0.019” x 0.025” rectangular NiTi followed by 0.019” x 0.025” rectangular stainless steel wires. Reverse curve of spee in the lower arch and exaggerated curve of spee in the upper arch was incorporated in the heavy archwires to prevent the excessive bite deepening during retraction process Case report
- 116. The maxillary and mandibular first molars were banded. The maxillary and mandibular teeth were bonded with 0,022-inch Roth brackets (Ortho Technology). Treatment was started using 0.012” NiTi , 0.014” NiTi, 0.016” NiTi, then 0.018” NiTi in both arches. Case report
- 117. The maxillary and mandibular 1st premolar of right side was first extracted. Complete bonding & banding in both maxillary and mandibular arch was done, using Pre-adjusted Edgewise bracket system. Initially a 0.012” NiTi wire was used which was followed by 0.014 , 0.016”, 0.018”, 0.020” Nitiarchwires following sequence A of MBT. After 6 months of alignment and leveling NiTi round wires were discontinued. Retraction and closure of spaces was then started by use of 0.019” x 0.025” rectangular NiTi followed by 0.019” x 0.025” rectangular stainless steel wires. Case report
- 118. Treatment was started using 0.016” NiTi in both arches, which was followed by 0.018” NiTi 0.019 × 0.025” NiTi. Finally, a 0.019” × 0.025” stainless steel wire was placed as a working arch wire. Leveling and alignment were completed in 5 months.
- 119. The treatment was initiated with a banding and bonding procedure using modified bidimen- sional preadjusted edgewise brackets, 0.018-inch slots in the incisors and canines, and 0.022-inch slots in the premo- lars and molars (3M Unitek, Monrovia, CA, USA). Roth prescription was combined with cementation of the quad helix appliance. Leveling and alignment were achieved with a straight wire technique which was used in the following sequence: 0.012′′ Niti, 0.014′′ Niti, 0.016′′ Niti, and 0:016 × 0:025′′ Niti followed by 0:018 × 0:022′′ SS wire
- 120. 0.022 x 0.028” slot MBT appliance was used in this case. Posterior leveling and aligning was initially done with round 0.014 and 0.016 Niti wires. 0.018SS archwire was used to make the Mulligan’s bypass arch. It was placed from canine to molars bilaterally bypassing incisors.
- 121. E-chain was placed from the molar tube to canine hook with the force of 100g . Individual canine retraction is carried about for 4 months and the anteriors were allowed to decrowd itself with driftodontics .
- 122. Meanwhile In upper arch, canine was pulled down with segmental wire. After the canine retraction in lower arch the anteriors were engaged with continuous archwire. E- chain was used for anterior space closure.
- 123. correction, 19x25 SS archwire was placed to co- ordinate the arches.0.021x0.025” braided SS was placed for finishing and detailing. Removable circumferential retainer and fixed retainer were given for retention. The total treatment time was 20 months. After space closure and midline