Methods of Gaining space

space is required for:

1. Correction of crowding.
2. Retraction of proclined teeth.
3. Derotation of rotated teeth. ?????
4. Leveling curve of Spee.
5. Management of increased overjet.
6. Correction of canine relationship.
7. Correction of molar relationship.
8. Improving face profile.
The various methods of gaining space:
1. Expansion.
2. Extraction.
3. Proximal striping.
4. Molars distalization.
5. Molars up righting.
6. Posterior teeth de-­­rotation.
7. By proclining anterior teeth.
8. Combination of the above.
1) Expansion
Can be divided into three categories:
a) Orthodontic expansion.
Expansion of dental arches or dento-alveolus, it is taken place by
buccal tipping of the crowns and lingual tipping of the roots.
b) Passive expansion.
By removing one of equilibrium forces like in Frankle appliance
by lip pads or buccal shields which holds the lip or cheek away
from the teeth and at the same time allowing tongue pressure to
move teeth outwards.
c) Orthopedic expansion.
Expansion of the basal bone or skeletal structure of the jaw
bones.
 Types of expansion according to the rate:
A)Slow Expansion:
• The rate of expansion is about 1 mm/week, which produces
about 2 pounds of pressure in a mixed dentition child,
• Opens the suture at a rate that is close to the maximum
speed of bone formation.
• The suture is not obviously pulled apart on radiographs,
• and no midline diastema appears,
• But both skeletal and dental changes occur.
• After 10 to 12 weeks, approximately the same roughly equal
amounts of skeletal and dental expansion are present that
were seen at the same time with rapid expansion.
Types of slow expansion
1)Removable
 Schwartz plate
 Coffin spring
 Active plate with double cantilever “Z” spring.
2)Fixed
 Quad Helix
 “W” appliance
 Arch wires in fixed appliances.
 Fixed Slow Expansion

Quad Helix W Appliance

Double Cantilever Z Spring Coffin spring
Removable
Slow
Expansion
B) Rapid Expansion
• Typically, rapid palatal expansion (RPE) is done with a
jackscrew that is activated at 0.5 to 1 mm per day.
• Although force levels can build up to 10 to 20 pounds
as the jackscrew is turned at that rate.
• The patient rarely experiences pain.
• Occlusal radiographs make it clear that the mid-palatal
suture does open.
• The expansion is obvious clinically because a diastema
appears between the maxillary central incisors.
• A centimeter or more of expansion is obtained in 2 to
3 weeks, with most of the movement being separation
of the two halves of the maxilla.
• The space created at the mid-palatal suture is filled initially by
tissue fluids and hemorrhage. After completion of the expansion,
a fixed retainer, usually the expansion device itself stabilized so
that it cannot screw itself back shut, is used for 3 to 4 months.
• By then, new bone has filled in the space at the suture, and the
expansion is complete.
• T h e midline diastema decreases and may disappear during this
time.
• Heavy force and rapid expansion are not indicated in the primary
or early mixed dentition.
• There is a significant risk of distortion of the nose if this is done in
younger children
• There is a risk of distortion of facial structures and neither no
evidence that rapid movement and high forces produce better or
more stable expansion
Types of rapid expansion:
1. Banded appliances:
 Hass type
 Issacson appliances
 Hyrax appliance
 Derischweiler appliance.
2. Bonded appliances
 Acrylic or cast metal splints.
Hyrax appliance
RPE Acrylic Bonded Appliance

Issacson appliances
• Surgically assisted rapid palatal expansion
(SARPE)
Osteotomy cut is made first and later the palate
is expanded using jack screw.
2) Extraction
The reasons for extractions:
1. Dento-alveolar discrepancy
In case of crowding for alignment of the remaining
teeth.
2. Correction of sagittal inter-arch relationship
a) In Angle’s class I molar, it is preferable to extract in
upper and lower arches.
b) In Angle’s class II molar, it is better to extract only
in upper arch, but in presence of crowding
extraction in lower arch may be necessary.
c) In Angle’s class III molar, it is better to extract in
lower arch only.
3. Abnormal number , size and form of the teeth, e.g.
supernumerary teeth , gemination, fusion, peg shape etc.
4. Retraction of protruded or proclined teeth.
5. In skeletal class II / III (camouflage treatment) , to obtain
correct incisor relation and molar relation in adult patient with
underlying skeletal discrepancy to improve facial aesthetics.
6. Preventive /interceptive treatment as in serial extraction.
7. When expansion is not possible because of age or nature of
malocclusion.
8. To shorten treatment time simplify correction, e.g. ectopic
canines or severely mal posed lower incisors (out of dental
arch)
9. In case of orthognathic surgery for alignment and make place
for osteotomy cut.
Consideration in choosing which tooth to be extracted
A)Condition of the teeth; fractured, hypoplastic, badly
decayed, heavily filled and poor prognosis RCT tooth
should be extracted in compare with sound tooth. The
decision should be balanced with treatment need and
other considerations.
B)Location of crowding; it is prudent to extract tooth
in site of crowding, but final position, contact,
aesthetic, stability and function have priority in
decision making.
C)Position of the teeth; ectopic, grossly mal posed,
and severely rotated tooth can be extracted.
D) Health of supporting tissues.
 Choice of individual teeth for orthodontic extraction
1)Indications for first premolar extraction:
 It is a preferred tooth for extraction because of:
 Erupts before any other posterior teeth.
 Each tooth gives 7-7.5 mm.
 The nearest tooth to the common site of crowding
of the six anteriors.
 Better anchorage can be achieved because it is in
the middle between the anterior and posterior
segments.
 Satisfactory contact between 2nd premolar and
canine and also gives good aesthetic and smile.
3)Indications for second premolar extraction:
 Gives better anchorage anteriorly.
 Posterior crowding.
 Good profile and mild to moderate crowding.
 In open bite cases.
 Class II div 1 dental with class I underlying
skeletal with mild mandibular crowding.
 Case of maxillary set back surgery.
 Crowded and out of dental arch.
1)Indications for permanent 1st molar extraction:
 Badly decayed or heavily filled with poor long term
prognosis.
 To avoid dished face in case of large nose and chin
which can be caused by extracting 1st or 2nd premolar
for better aesthetic.
 In open bite cases.
 In case of severe over eruption.
 It is not prudent to extract this tooth because of poor
contact between 2nd premolar and 2nd molar which can
cause food lodgment in the gap but timing of
extraction and other consideration should be taken in
account to overcome these problems.
4)Indications for incisors extraction:
 Extraction of upper central incisors are rarely
unless have poor prognosis, mobility,
dilaceration, fusion or severely impacted. The
same would be for upper lateral incisors.
 Extraction of lower incisors if it is severely
crowded and totally out of dental arch,
periodontal breakdown, severely fractured,
large Bolton’s discrepancy, in mild class III with
crowding and in distally inclined canines.
5)Indications for canine extractions
 They are the corner teeth and very important for
aesthetic and their absence could cause flattening
of the face and alternation in facial balance and
expression, only can be
extracted in the following situation:
 Horizontally impacted
 Severely ectopic
 Periodontally weak
 In case of perfect contact between 1st premolar and
lateral incisor and palatal cusp of the premolar is
not visible.
6)Indication for extraction of 2nd molar:
 Before distalizing first molars.
 In open bite cases for deepening the bite.
 Relieve impaction of 2nd premolar and reduce
impaction of 3rd molar.
 In case of badly decayed or severely ectopic or
impacted (2nd premolar should be present and
normal morphology)
7)Indication for extraction of 3rd molars;
3.Proximal striping/slicing/disking/reproximation
 It is reduction of the proximal surface of adjacent teeth.
 Enamel reduction should not more than 0.25mm on each side of
the tooth.
 Commonly performed in lower anterior teeth but can be done on
any segment including upper anteriors.
 Ideally should include large number of teeth instead of removing
too much enamel from few teeth.
 It is applicable in a minimal space required 2.5-3mm to avoid
extraction.
 Border line cases to avoid extraction.
 To add retention in case of severe lower incisors crowding.
 It is contraindicated in young children (large pulp chamber) and
where enamel thickness is low and in case of high caries index.
 Fluoride application must be done after striping especially in
cases of high caries index.
 Intra oral periapical and bite wing radiographs should be
taken to asses the enamel thickness at striping sides.
Advantages of striping:
 Avoids of extraction especially in border line cases.
 Favorable overjet and overbite can be established.
 Stable results by broadening proximal contact.
 Less painful.
Disadvantages of striping:
 Rough striped surface then more plaque and increase risk of
caries.
 Teeth may become sensitive.
 Improper reduction may affect in aesthetic.
 Excessive reduction may promote food lodgment.
4. Molar distalization
 It is method of gaining space where molars
usually 1st and 2nd are moved back to give space
in front of them.
 It is especially done for non-extraction
treatment of class II malocclusion.
 It can be obtained by intraoral appliance or
extraoral appliance like headgear.
 It is indicated in moderate cases of maxillary
protrusion and arch length deficiency and
where extraction is not indicated.
Head Gear
5.Molars up righting.
 If 2nd premolar or deciduous 2nd molar was prematurely
extracted and space not maintained or tooth replaced, the
1st permanent molar (or even 2nd and 3rd molar) would
drift, rotate and tilt mesially into the available space.
 It will cause food trap and risk of caries.
 Molar upright return tooth to its normal angulation,
occlusal contact and gain the lost space.
 The gained space can be used for correction of
malocclusion.
 This procedure usually takes few months to a year for
completion.