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FINAL YEAR CLINICALS

GENERAL INFO:

 MALOCCLUSIONS AND ETIOLOGY (Graber).

 Tooth eruption schedule for primary and permanent teeth, morphology of

primary and permanent teeth

 DECIDUOUS DENTITION - features including spaced dentition vs closed

dentition, primate spaces, terminal plane relationship
 MIXED DENTITION- including incisal liability, ugly duckling stage, leeway
space of Nance, terminal plane relationship and transition of molar-
occlusal relationship from mixed dentition to permanent dentition
 PERMANENT DENTITION – features of normal occlusion

 Muscles of mastication

 Diagnostic Aids
 Radiographs
 Lateral Cephalogram, OPG, PA Cephalogram. Hand-Wrist
Radiographs. Maxillary Occlusal Radiographs
 Which type of cephalogram is used to assess skeletal base?
 Which type of cephalogram is used in case of facial asymmetry?
 Which radiographs are used to assess skeletal maturity?
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CASE SHEET FORMAT

CASE HISTORY

1. Personal Details

 Name
 Age
 Sex
 Education/Occupation
 Address

2. Chief complaint

 Family History
 Prenatal history
 Postnatal history
 Medical history + allergy history
 Dental history

CLINICAL EXAMINATION

3. General examination:

 Height (cm)
 Weight (kg)
 Gait
 Head posture
 Body type
 Cephalic Index (measurement)

4. Extra-oral examination:

I. FRONTAL
 Facial form (measurement)
 Symmetry:
o Bird’s eye view/worm’s eye view
o Rule of 5
o Rule of 3 (vertical facial proportions) (measurement)
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o Occlusal cant (asymmetry in transverse plane)

 Interlabial gap (mm)
 Upper lip length (mm)
 Mentalis activity
 Lip posture/tonicity
 Incisor and gingiva visibility
 Smile arc – consonant/non-consonant

II. PROFILE

 Facial Profile Analysis/ Poor man’s cephalometrics:

1. Facial profile
2. Facial divergence
3. Nasolabial angle
4. Clinical FMA
5. Lip posture/ competence (FRONTAL)
6. Vertical facial proportions/ rule of 3 (measurement) (FRONTAL)

 Mentolabial sulcus
 Chin position
 Nose- size and shape
 E-lIne (Rickett’s)

 Ballard’s technique

 Clinical VTO (If patient has a moderate to severe Class II or Class III skeletal base)

5. Functional Examination:

 Speech
 Deglutition (check for tongue thrust)
 Respiration
o Mouth breathing tests
 TMJ
o Pain
o Tenderness on palpation
o Clicking
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o Deviation on opening and closing

 Maximum mouth opening (measurement)

 Freeway space (Vertical dimension at rest – vertical dimension on occlusion)(measurement)

6. Intra-Oral Examination:
Soft tissue examination:
 Gingiva
 Frenal attachments (blanch test if needed)
 Tongue
 Palate
 Tonsils
 Cheeks

Hard tissue examination: (Intra-arch examination and Inter-arch examination)

Intra-arch examination
 Missing teeth, supernumerary teeth, retained deciduous?
 Individual tooth malpositions including malformations, rotations, transpositions as well as
crowding and spacing.
 Angle’s line of occlusion
 Arch form
 Carious teeth
 Oral hygiene

Inter-arch examination:

I. Anteroposterior/sagittal

 Angle’s molar classification

o Class I
o Class II
 Class II division 1 (upper anteriors proclined)
 Class II division 2 (upper anteriors retroclined)
 Class II subdivision (Class II molar on one side and Class I on the other)
o Class III
 Class III subdivision (Class III molar on one side and Class I on the other)
o Pseudo-Class III
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 Canine classification: I, II or III

 Incisor classification: I,II or III
 Overjet (mm)

Ii. Vertical

 Overbite (mm)
 Open bite (anterior or posterior)
 Deep bite (anterior)

Iii. Transverse
 Cross-bite including scissor bite
 Midlines:
o Check if the facial and maxillary midlines are congruent.
o Check if the facial and mandibular midlines are congruent
o Check if the maxillary and mandibular midlines are congruent.

Measurements to be taken:

a) Overbite (mm)
b) Overjet (mm)
c) Vertical height at rest and vertical height in occlusion (mm)
d) Maximum mouth opening (mm)
e) Facial thirds (mm)
f) Cephalic Index
g) Facial Form
h) Height (cm)
i) Weight (kg)
j) Interlabial gap (mm)
k) Upper lip length (mm)

7. Diagnosis:

• A _ _ year old pre/post-pubertal male/female patient with

• Angle’s Class I/II/III malocclusion on a
• Class I/II/III skeletal base with a
• Class I/II/III canine relation and
• skeletal problem (if present) in sagittal/transverse/vertical planes and
• dental problems (intra-arch if present) and (inter-arch- if present) in
sagittal/transverse/vertical planes and
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• Soft tissue problems (if present) e.g. convex/ concave profile, increased/decreased
nasiolabial angle, and deep/shallow mentolabial sulcus, incompetent/potentially
incompetent lips and
• habits (if present)

8. Treatment Objectives:

9. Treatment Plan:

Extraction or non-extraction decision to be determined following assessment of patient’s soft

tissue profile and then model analysis and cephalometric analysis.

10. Mechanotherapy:

Removable Appliance or Dentofacial Orthopedics or Orthognathic Surgery

and

Fixed Orthodontic Appliance

11. Retention:

a. Short Term: Hawley’s retainer/ Begg’s wraparound retainer/Essix retainer

b. Permanent: Fixed lingual retainer

12. Prognosis: Good/Fair/Poor

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CASE HISTORY AND CLINICAL EXAMINATION (additional notes and Qs)

Observe the patient’s gait as they walk to the dental chair and seat themselves. Abnormal gait could
indicate a neuromuscular problem which could affect normal growth and development.

Check patient’s facial profile- would we want to change the profile or maintain it?

CASE HISTORY:

Personal details- ask for name, age, address, and education/occupation.

• Relevance of each personal detail.

• The age you ask the patient is it chronological, dental or skeletal? What is the difference
between the three?
• Transient malocclusion?
• Growth spurts?
• Education/ Occupation – for treatment understanding and expectations
• Motivation – Types of motivation – Internal/External

Chief complaint. Write down the chief complaint in patient’s own words- no technical terms like
anterior, posterior, maxilla, mandible, protruded, prognathic, buccal, labial, etc.

 Family history: including Parents- consanguineous marriage or not? Whether parents or siblings
have a similar malocclusion
o What does consanguineous mean?
o What is Hapsburg jaw?

 Prenatal history: including mother’s condition during pregnancy, premature or normal birth,
type of delivery- forcep delivery?
o What are teratogens?
o Drugs taken during which trimester is more likely to result in developmental
anomalies in the child? Why?
o Fetal alcoholic syndrome?
o Intrauterine fetal moulding
o Why do we ask whether the delivery was full term or premature?
o What is the significance of forceps delivery to Orthodontics?
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 Postnatal history including weaning period, milestones and habits. Habits- duration, frequency
and intensity
 Processes involved in breast feeding and bottle feeding?
 Duration of feeding.

 Milestones

 Habits
 Definition.
 Habits - frequency, intensity and duration- which of these is most important?
 What is the minimum duration required for a habit to bring about tooth
movement?
 What are secondary messengers? How are they involved with tooth
movement?
 Methods to diagnose each habit.
 Types of malocclusion caused by each habit and treatment for each.

 Infantile swallow. Adult/mature swallow. Retained infantile swallow.

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Habit Malocclusion Treatment

Thumb- Proclined upper incisors Beta Dunlop Hypothesis

sucking Retroclined lower incisors Behaviour Therapy
Increased overjet Reminder Therapy
Anterior openbite Palatal crib/tongue guard appliance
Posterior crossbite Blue grass appliance

Tongue Proclined, spaced upper anteriors- resulting Palatal crib/tongue guard appliance and
thrusting in increased overjet. active labial bow
Proclined lower anteriors.
Anterior open bite Double oral screen
Posterior crossbite
Bimaxillary protrusion

Mouth Increased overjet Oral screen

breathing Anterior openbite Lip exercises
Posterior crossbite Rapid maxillary expansion
High palatal vault

Bruxism Attrition of dentition. Occlusal splint

TMJ pain Occlusal Equilibration

Lip biting Protrusion of maxillary incisors and Lip bumper/plumper

retroclined lower anteriors
Cracking of lip

Nail biting Rotation of incisors, Beta Dunlop Hypothesis

Wear of incisal edge Behaviour therapy
Minor crowding Reminder Therapy
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 Dental history- if previous ortho treatment- ask about previous chief complaint, whether
treatment was completed and about retainer use following treatment.
o Including history of extractions and timely exfoliation of deciduous teeth and eruption
of permanent teeth.

o Details of previous orthodontic treatment- (if any) including previous chief complaint
and whether the previous treatment was satisfactorily concluded? Was there a
relapse and why?

 Medical history including allergy history.

o Current and past medications?
o Any visits to a hospital or doctor in the past? Any surgeries?
o Medically compromised patients- Pregnancy, Diabetics, Cardiac patients, Blood
dyscrasias, Epileptics, etc and how they affect Orthodontic treatment.
o Drugs and Orthodontic Tooth Movement
o ALLERGIES: Drug, latex, Metal, Acrylic, antibiotics, local anaesthetic.
Alternatives for each. Allergy to Medications.

By this point you should have an idea of how motivated the patient is (internal vs external motivation),
what their expectations are of the treatment, whether the expectations are realistic or not, etc.

CLINICAL EXAMINATION:

General examination:

 Body build classification. Who gave the classification? Relevance?

 Posture- relevance
 Gait – relevance and types.

Extra-oral examination:

 Cephalic Index and facial form. There is a correlation between the two and an expected dental arch
form for each type.

 Facial Profile Analysis/ Poor man’s cephalometrics:

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1. Facial profile (straight, convex or concave profile)

2. Facial divergence
3. Vertical facial proportions/ rule of 3
4. Lip posture/ competence (competent, incompetent, potentially incompetent or
everted). This has to be assessed when the facial muscles are at rest. If there is
puckering of chin/ hyperactive mentalis, then the facial muscles are not at rest. A space
of up to 4mm between the lips can be considered as competent)
5. Nasolabial angle (normal – 90 to 110 degrees, acute or increased. Tells us about upper
incisor inclination)
6. Clinical FMA (average, horizontal or vertical growth of mandible)

 Mentolabial sulcus (tells us about lower incisor inclination)

 Ballard’s technique (tells us about skeletal base- Class I, II or III)

 Clinical VTO: If patient has a moderate to severe Class II or Class III skeletal base, clinical VTO will
tell us which jaw (maxilla or mandible) is the cause of the problem.

 Lip step by Korkhaus (Class I, II or III case)

 Rickett’s Esthetic plane/ line : E-line is a line joining the tip of the nose and chin. Normally upper
lip is 4mm behind and lower lip is 2mm behind this line. If the lips are on the line or ahead of the
line- extraction may be needed with retraction of teeth. If lines are far behind the line,
expansion and/or anterior movement of teeth may be needed.

Functional Examination:

 Speech:
You should have noticed any abnormalities in speech while taking case history. Certain
malocclusions and conditions can cause different types of speech abnormalities e.g. anterior
open bite, midline diastema, CLP, ankyloglossia

 Deglutition:

Check for tongue thrusting.

Ask the patient to swallow. See if there’s any involvement of circumoral or muscles of facial
expression, bowing of the head, i.e. features seen in retained infantile swallow.

Part the lips using the mouth mirror or gloved hand and ask the patient to swallow again. Check
to see if the teeth are together and whether or not the tongue is enclosed behind the dentition.
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 Respiration:
Observe the patient when they are relaxed. Is the patient a nasal, oral or oro-nasal breather?
Mouth breathing tests: Double mirror, cotton butterfly and water-holding test.

 TMJ (+ maximum mouth opening):

Auscultatory method of examination involves a stethoscope. You can appreciate clicking and
crepitus with this method.

Palpatory method can be pre-auricular or intra-auricular method.

When assessing the TMJ, check for:

o Tenderness on palpation
o Clicking
o Deviation on opening and closing

 Maximum mouth opening:

Use a ruler to measure the maximum mouth opening or use the finger method (note: use the
patient’s fingers- not your own).

 Determine freeway space (Vertical dimension at rest – vertical dimension on occlusion)

Vertical dimension at rest aka postural rest position can be determined when the patient’s
musculature is relaxed. This can be achieved following:
o Phonetic method .e.g. ask the patient to say ‘M’ repeatedly
o Command method: ask the patient to swallow
o Non-command method. Patient is distracted so muscles are relaxed
o Combined methods: observed during functions and manually guided by tapping the chin

Intra-Oral Examination:

Soft tissue examination:

 Gingiva- pockets, indications of periodontal disease

 Labial frenum: Blanch Test if thick or highly attached. (Check especially in case of midline
diastema)
 Tongue: check for macroglossia, increased length, ankyloglossia, tongue thrusting, etc.
 Palate- CLP, High vault palate, etc
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 Tonsils – enlarged tonsils could lead to mouth breathing

 Cheeks- cheek bite

Hard tissue examination:

Intra-arch examination: : (Quadrant-wise examination)

Inter-arch examination: (observe the upper and lower arch relations with the teeth in occlusion)
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DENTOFACIAL DEFORMITY – DIAGNOSTIC FEATURES

CLINICAL DENTAL ASSESSMENT SKELETAL ASSESSMENT

FEATURES
MAXILLA SAGITTAL  Concave profile  Class III • SNA decreased
DEFICIENCY  Retrusive  Maxillary dental • SNB normal
upper lip crowding • ANB decreased
 Alar base  Maxillary incisors
narrow proclined
 Lack of dental  Mandibular incisors
display normal or
retroclined

MAXILLA SAGITTAL • Convex profile

EXCESS • Acute
nasolabial
angle

MAXILLA VERTICAL • Convex profile • Class II, Class I

EXCESS • Lower facial • Anterior open bite
(LONG FACE height • Maxillary arch
SYNDROME) increased constricted
• Alar base • Curve of Spee- flat
constricted or accentuated
• Nasolabial • Dental crowding
angle acute
• Excessive
incisor show
• Excessive
gingival show
• Lip
incompetence
• Mentalis strain
with lip closure
• Chin vertically
long, retruded

MAXILLA VERTICAL • Concave profile • Class II, Class I • Lower facial height
DEFICIENCY • Lower facial height • Deep bite decreased
(SHORT FACE decreased
• Nasolabial angle • Crowding in lower • SNB increased
SYNDROME)
varies arch • ANB negative
• Alar base widened • Curve of Spee is • Palatal-occlusal
• Lack of incisor reverse plane decreased
show
• Edentulous
• Mandibular plane
appearance angle acute
• Chin protruded
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CLINICAL DENTAL ASSESSMENT SKELETAL ASSESSMENT

FEATURES
MANDIBLE DEFICIENC • Convex profile • Class II • SNA normal
Y • Retruded chin • Mandibular incisors • SNB decreased
• Lower lip proclined • ANB increased
everted • Maxillary incisors • Ar-Gn decreased
• Deep proclined
mentolabial • Curve of Spee
crease accentuated
• Mentalis strain
with lip closure

MANDIBLE EXCESS • Concave profile • Class III • SNA normal

• Midface • Maxillary incisors • SNB increased
appears proclined • ANB decreased
deficient • Mandibular incisors
• Lower third retroclined
broad
• Lower lip thin
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7. DIAGNOSIS

• A _ _ year old pre/post-pubertal male/female patient with

• Angle’s Class I/II/III malocclusion on a
• Class I/II/III skeletal base with a
• Class I/II/III canine relation and
• skeletal problem (if present) in sagittal/transverse/vertical planes and
• dental problems (intra-arch if present) and (inter-arch- if present) in
sagittal/transverse/vertical planes and
• Soft tissue problems (if present) e.g. convex/ concave profile, increased/decreased
nasiolabial angle, and deep/shallow mentolabial sulcus, incompetent/potentially
incompetent lips and
• habits (if present)

 Patient’s chief complaint must be addressed in the diagnosis.

 Mention Angle’s molar relation, skeletal base and canine relation (whether normal or
abnormal) and then mention only abnormal findings.
E.g.
A 20-year-old post-pubertal female patient with Angle’s Class I malocclusion on Class I
skeletal base with Class I canine relation and severe crowding in the lower anteriors,
with an overjet of 5mm and overbite of 4mm with a convex profile and an acute
nasolabial angle.

8. TREATMENT OBJECTIVES:
Simply list out all the problems mention in the diagnosis that you intend to
correct .e.g. correct midline diastema.

 What is Orthodontic triage?

9. TREATMENT PLAN:
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Extraction or non-extraction decision to be determined

following assessment of patient’s soft tissue profile and then
model analysis and cephalometric analysis.

 What is the hard tissue or Angle paradigm? What is the soft tissue
paradigm?
 Which paradigm is considered relevant today?

MODEL ANALYSIS
1. What is a study model?

2. What are the parts of a study model?

3. Classification of Model Analyses

Model Analysis:

 Pont’s analysis will tell you if expansion is possible.

 Ashley Howe’s analysis will help you decide whether the first premolars have to be
extracted.
 Carey’s /Arch Perimeter analysis will help you decide whether sufficient space can
be gained by extraction of first premolars or second premolars or whether proximal
stripping is sufficient.
 Bolton’s analysis will tell you if there is a tooth size discrepancy between the upper
and lower teeth.

CEPHALOMETRICS
 Classification of cephalometric analyses

Cephalometric analyses (Down’s, Steiner’s, Tweed and Wits) will tell you:

 Whether the skeletal base is Class I, II or III.

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 Whether the maxilla or mandible is prognathic or retrognathic

 If the upper or lower incisors are proclined or retroclined.
 If the patient’s mandible is horizontally growing (anti-clockwise growth and low angle
case) or vertically growing (clockwise growth and high angle case).

DOWN’S ANALYSIS

 What are the two components of Down’s Analysis?

 Down’s Skeletal Analysis

 Which angle will tell you whether the mandible is prognathic or retrognathic?
What is its normal range?
 Which two lines form the facial angle?
 Which angle will tell you about whether the maxilla is retrognathic or
prognathic?
 Which two lines form the angle of convexity?
 Which angle will indicate whether a case is Class II or Class III?
 Which two angles will tell you if the patient has a vertically or horizontally
growing mandible?

 Down’s Dental Analysis

 Which angle will tell you if the mandibular ramus is long or short? How is it
measured? Normal value?
 Which angle will tell you whether the upper and lower incisors are proclined or
retroclined? What is the normal range?
 Which two angles will indicate whether there is lower incisor proclination?
 What linear measurement will indicate whether or not the upper incisors are
protruded or retruded?

STEINER’S ANALYSIS

 What are the three components of Steiner’s Analysis?

 Steiner’s Skeletal Analysis

 Which angle indicates maxillary prognathism or retrognathism? What is its
normal value?
 Which angle indicates mandibular prognathism or retrognathism? What is its
normal value?
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 Which angle indicates whether a case is Class II or Class III? What is its normal
value?
 What does an increased ANB angle indicate? What does a decreased ANB angle
indicate?
 Which two angles will tell you if the patient has a vertically or horizontally
growing mandible? What are their normal values?

 Steiner’s Dental Analysis

 Which angle will tell you if the upper incisors are proclined or retroclined?
Normal value?
 What linear measurement will tell you if the upper incisors are forwardly or
backwardly placed? Normal value?
 Which angle will tell you if the lower incisors are proclined or retroclined?
Normal value?
 What linear measurement will tell you if the lower incisors are forwardly or
backwardly placed? Normal value?
 Which angle will tell you whether the upper and lower incisors are proclined or
retroclined? Normal value?

 Steiner’s Soft Tissue Analysis

 Which linear measurement will tell you whether the lips are protusive or
retrusive? Normal value?

TWEED’S ANALYSIS

 Which angle tells you whether the mandible is horizontally growing (low angle and
clockwise growth) or vertically growing (high angle and anti-clockwise growth? What is
the normal value?
 Which angle tells you whether the lower incisors are proclined or retroclined? What is
the normal value?
 What is the normal value for Frankfort mandibular incisor plane angle (FMIA)? What
does a decrease in the angle indicate?

WITT’S APPRAISAL

 What is the normal relation of AO to BO in males and females?

 What is the relation of AO to BO in a Class II Skeletal base?
 What is the relation of AO to BO in a Class III Skeletal base?
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Name 7 methods of gaining space. (P2E2D2U)

EXTRACTION DECISION CONSIDERATIONS:

If you are extracting on one side of the arch, you will have to extract on the other
side to maintain symmetry and prevent mid-line shift. (Balancing extraction)

For every millimeter of retraction required, 2 mm of space is required.

For every millimeter of decrowding, the same amount of space is required for
aligning the teeth

For every millimeter of derotation required in the anterior segment, the same
amount of space is required for aligning the teeth.
Space is created when rotated posterior teeth are aligned. The space created
depends upon the tooth and the amount of rotation present.
For every 1 mm of leveling of the Curve of Spee, approximately 1 mm of space is
required.

In a Class I bimaxillary dental protrusion case (with a convex profile), extract from
both arches to achieve the desirable straight profile and Class I molar relation.
(Compensating extraction)

In a case with Class II tendency or for orthodontic camouflage in a Class II case,

extract from upper arch. This will correct the convex profile.
In such a Class II case, if extraction is required in the lower arch (in case of
crowding), try to extract further distally in the lower arch.
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In a case with Class III tendency or for orthodontic camouflage in a Class III case,
extract from lower arch. This will correct the concave profile.
In such a Class III case, if extraction is required in the upper arch (in case of
crowding) try to extract further distally in the upper arch.

If the profile is fairly straight and extraction is needed, extract further distally in
the arch .e.g. 2nd premolars.

Rickett’s Esthetic line – If the lips are on or ahead of the E-line, consider
extraction.

An acute nasolabial angle often indicates extraction.

In case of severe skeletal discrepancy in adults requiring surgical orthodontics:

 Orthognathic surgical correction of skeletal class II often requires upper 5s
and lower 4 extraction for decompensation.
 Orthognathic surgical correction of skeletal class III often requires upper 4s
and lower 5 extraction for decompensation.
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10. MECHANOTHERAPY:
a. Removable appliance (not applicable in moderate to severe skeletal cases-
those cases might require dentofacial orthopedics in growing patients or
orthognathic surgery in adult patients)

b. Fixed: Fixed Orthodontic Appliance (preferable if you can mention the elastics
or types of springs used in fixed orthodontics relevant to the case )

 Envelope of Discrepancy.

 Class I Malocclusions- Intra-Arch, Transverse and Vertical Malocclusions :

Open Bite + Deep Bite, Cross Bite, Midline shift and Treatment modalities
for each.

 REMOVABLE APPLIANCES:
 Various Malocclusions and the Removable Appliances/Components to
Treat Them
 Hawley’s APPLIANCE vs. Hawley’s RETAINER
 Removable Appliances – Indications and Limitations.
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 FIXED APPLIANCES:
 Fixed Orthodontic Appliance + elastics used (if any)
 What is NiTi and Stainless Steel archwires used for?
 What are open and closed coil springs used for

CLASS II OR CLASS III SKELETAL CASES:

 Clinical VTO for Class II and Class III cases

TREATMENT MODALITIES FOR SKELETAL DISCREPANCIES [CLASS II and CLASS III]:

 Based on age of patient/ growth potential- what type of treatment is

possible?

A. Growing patients with skeletal jaw discrepancies (Class II or Class III)

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DENTOFACIAL ORTHOPEDICS

Myofunctional appliances (Retrognathic mandible or maxilla)

a. Name four functional appliances used for correcting a retrognathic

mandible.
b. Name four functional appliances used for correcting a retrognathic
maxilla.

Orthopedic appliances (Prognathic maxilla or mandible, retrognathic maxilla)

c. Name an orthopedic appliance used for correcting a prognathic

maxilla
d. Name an orthopedic appliance used for correcting a retrognathic
maxilla
e. Name an orthopedic appliance used for correcting a prognathic
mandible.

B. Adult patient with skeletal jaw discrepancies (Class II or Class III)

 Camouflage treatment (Fixed Orthodontic Treatment only)

 Surgery
a. What is decompensation/ reverse orthodontics?
b. What kind of extraction pattern is advised in a Class II and Class III
case for decompensation?
c. What is a common surgical procedure used for bringing forward the
mandible/ setting back the maxilla?
d. What is a common surgical procedure used for bringing forward the
mandible/ setting back the mandible?

11. RETENTION
a. Removable retainers for short term retention: Hawley’s RETAINER, Begg’s
Wraparound Retainer, Essix Retainer, etc.
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b. Fixed retainers for long term retention (if needed) :Lingual Bonded
Retainer

12. PROGNOSIS
Good/Fair/Poor

 In case of syndromes or severe skeletal malocclusion, requiring

orthognathic surgery, prognosis drops from good to fair/poor.
 In case of periodontally compromised patients, prognosis drops from
good to fair/poor
 In case of complicated cases i.e. multiple impactions, multiple rotated
teeth, etc., prognosis drops from good to fair/poor.
 In case of a habit, prognosis can drop from good to fair, especially in older
patients.
 Patient’s oral hygiene and attitude towards treatment including
motivation affects prognosis to a lesser degree.
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WIRE BENDING CHECKLIST

Adams’ Clasp
Fabricated using 21 gauge wire (0.7mm).

Bridge:

1. Width of bridge equal to two-thirds of mesio-distal width of tooth.

2. Bridge should be located at middle third of tooth.
3. Bridge should be 2mm from tooth surface.
4. When viewed from the side, bridge should be at 45 0 to the buccal tooth surface.
5. Bridge should be parallel to the buccal surface.

Arrowhead:

1. Arrowhead should be at 450 to the bridge.

2. Arrowheads should have a point contact than a surface contact.
3. Arrowheads should be positioned at the buccoproximal undercut areas.
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Retentive arm:

1. Retentive arm should not interfere with the occlusion. Cross-over wire should rest inter-
dentally.

Adjustment of Adams’ Clasp:

Clasp is activated in two positions:

1. Position A: The bends are made just beyond the point where the tag bends down towards the
arrowhead. Adjustments of clasps is done by bending the retentive points inwards. This is useful during
initial placement of appliances.

2. Position B: Tightening of the clasps at the point of emergence from the base plate. This is the usual
place of adjustment after repeated insertion and removal.
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Labial Bow

Fabricated using 21 gauge wire (0.7mm).

Bow:

1. Horizontal bow portion is in the middle third of teeth (retention labial bow).
2. Bow must contact the labial most anterior teeth.
3. Bow must be fabricated using fingers and not pliers. No sharp bends should be present in the
bow.

U-Loop:

1. Vertical bend or the right angled bend, to form the loop, is given at the mesial one third of
canine (short labial bow for retention).
2. Loops should extend 2 mm past the gingival margin. They should be short of the sulcus to avoid
irritation.
3. Loop should be approximately the width of a first premolar.
4. The mesial and distal arms of the loop should be parallel to one another.
5. The mesial and distal arms should be on the same plane.
6. No bends should be incorporated on the mesial and distal arms of the U-loops.
7. Loops should not contact the gingiva.
8. Loops should not impinge on the lips.
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Retentive arm:

2. Retentive arm should not interfere with the occlusion. Cross-over wire should rest inter-
dentally.

Activation of Labial Bow (For retraction labial bow in a Hawley’s appliance):

Compress the U loops.

BEGG’S WRAPAROUND LABIAL BOW

• ’U’ loops made between 1st & 2nd premolars to close the spaces where the molar bands were.

• In orthodontically treated cases (especially where premolars were extracted), if you give a
Hawley’s retainer, the cross-over wire of the labial bow between the canine and premolar can
act as a wedge and open up a space between the two teeth.

• In Begg’s labial bow, no such cross-over wire is present. So there is no risk of the space opening
up between the canine and premolar.
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Why are there errors in the appliance following

acrylisation?

 Polymerisation shrinkage.
 Operator error during acrylisation.
 Distortion of wire components as the appliance is held by the clasps
during finishing and polishing.
 Inaccurate positioning of the wire components i.e. improper stabilization
of wire components during acrylisation.
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Laboratory:

After trimming and polishing the appliance, check the crossover wires to make
sure there’s no acrylic on the underside of the wire. This will prevent the
appliance from fitting into the patient’s mouth

Make sure there are no sharp edges or rough surfaces on the acrylic base plate.

DELIVER OF THE APPLIANCE (CHAIRSIDE):

Check for 4 things at chairside when delivering the appliance:

1. Fit
2. Pain
3. Occlusal interference
4. Retention of the appliance

1. Fit:

Does the appliance fit in the patient’s mouth properly?

2. Pain:

Does the patient complain of any pain? Some discomfort is expected but pain is
not acceptable. Make sure the wire components e.g. the U-loops of the labial
bow, are not impinging on the soft tissue.

3. Occlusal interference:

Compare the patient’s occlusion with and without the appliance in place. If there
is a difference, there is some occlusal interference. Check to see where there is
interference, ask the patient to localize where the interference is.
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4. Retention of the appliance:

Talk to the patient and then ask the patient to recite the alphabet. Check if the
maxillary appliance stays on and that the mandibular appliance is not displaced by
the tongue or lingual frenum.

If the appliance fits, there is no pain, no occlusal interference and retention is

present, then it’s time to train the patient on how to put on and remove the
appliance.

Training the patient:

Explain the parts of the appliance to the patient.

Instruct the patient to hold the appliance only from the posterior aspect i.e. clasps
when taking and putting on the appliance.

Tell them NOT to hold the appliance from the front i.e. by the labial bow.

Instruct the patient on how to put on the appliance and remove it.

Ask the patient to put on the appliance, then remove it and drop it in a bowl of
water.

Once the patient can repeat this three times without any assistance, then you can
tell them the rest of the instructions.
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INSTRUCTIONS TO BE GIVEN TO THE PATIENT FOR REMOVABLE RETAINERS

1. Appliance should be worn all the time, even during sleep.
2. Remove the appliance while eating hard or hot foods as there are chances of
distortion.
3. Remove the appliance using the clasps only.
4. Remove the appliance only during brushing.
5. Clean the appliance every day and after every meal. Clean the appliance using a soft
toothbrush and a denture cleaning paste. It should be rinsed in clean water after every
meal. Commercial denture/retainer cleansers can also be used to clean the appliance.
6. Advice the patient to avoid playing with the appliance using the tongue. This makes
the appliance less retentive and can distort the components.
7. Storing the appliance: At any time if the patient is unable to wear the appliance he or
she should leave the appliance in water in a closed container.
8. Patient may face one or few or all of the following problems initially
1. Discomfort
2. Pain or tenderness in the teeth being moved
3. Excessive salivation
4. Plastic taste
5. Difficulty in speech
All the above problems will be overcome in a few days’ time if the patient
wears the appliance regularly.
9. If any part of the appliance is broken, he or she should discontinue wearing the
appliance and should report to the orthodontist at the earliest
10. If there is severe pain at any stage during the treatment the patient is advised to
remove the appliance and report to the orthodontist at the earliest.
11. The appliance should be never be wrapped in paper or napkins or stored in the pocket
as it leads to the distortion of the wire components.
12. The patient should be instructed not to leave the appliance out of the mouth for a
long period of time as it increases the risk of distortion.
13. Patient is advised to return to the orthodontist for activation, monthly or whenever
the appliance is loose.
14. Patient is advised to wear retainers full-time for at least 12 months.
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Adjustment or Activation of Removable appliances:

 If an appliance e.g. Hawley’s retainer is loose, you have to adjust the Adam’s clasps at two
points.
 To activate a Hawley’s appliance (retraction labial bow), compress the U-loops of the labial
bow.

Appliances should be delivered to the patient within 48 hours of taking their impression.

What is the use of a Hawley’s retainer?

What is the use of a Hawley’s appliance?

What are the 3 physical differences between a labial bow used for retraction and a labial bow used for
retention?

What are the 4 physical differences when fabricating a Hawley’s retainer and a Hawley’s appliance?

How do you activate a Hawley’s appliance?

How do you adust an appliance with (Adam’s clasps) that is loose? Which two points on the Adam’s
clasp will you adjust?

What is a guided spring? How do you do the boxing of a guided spring?

What are possible errors that can occur during acrylisation?

When do we give a Begg’s wraparound retainer? What advantages does it have over Hawley’s retainer
in a patient treated with first premolar extraction?

Indications for the following:

 Anterior bite plane
 Posterior bite plane
 Posterior bite plane along with a Z-spring
 Long labial bow
 Tongue crib
 Oral screen
 Double oral screen