O

.014

Fig. 5.34 In some cases, the authors can follow sequence B to complete a treatment with very efficient mechanics and few archwire changes. However, in many treatments it is necessary to use some wires from the more traditional sequence A, and these are discussed below.

HE AT-ACTIVATED NICKEL-TITANIUM (HANT) OR STAINLESS STEEL?

Because of their flexibility, there are clinical situations where heat-activated wires are not recommended, or where some stainless steel wires should also be used. These clinical situations are described below:

• Initial wires in cases with severe malalignment of teeth. It is a service to the patient to place a multistrand wire as the first wire in such cases. The permanent deflection that occurs with these wires reduces the overall force levels and produces less discomfort during the initial 'experience with braces'. Also, some wire bending in addition to the normal arch form may be required, and is easily accomplished with multistrand wires.

• For complete arch leveling and overbite control. While heat-activated wires are excellent for individual tooth alignment, they are not effective for complete arch leveling and subsequent bite opening. I lence, the transition from even the rectangular heat-activated wires to the rectangular stainless steel wire is sometimes impossible. A .020 round steel wire is often required before the rectangular stainless steel wire.

• For torque control. Rectangular heat-activated wires commence the process of torque control, but this difficult tooth movement is best completed by using a rectangular stainless steel wire.

• When using lacebacks for cuspid retraction in crowded extraction cases. The use of lacebacks minimizes the tipping of the cuspids into the extraction sites. However, with prolonged use of flexible heat-activated wires, some tipping can occur. To reduce this possibility, a .018 or .020 stainless steel wire should be used as early as possible when using lacebacks.

• When using open coil spring in the anterior or posterior segments to create space for blocked-out teeth. Because of their flexibility, the use of open coil springs on heat-activated wires can cause significant distortions in arch form. Thus, open coil springs should not be used until .018 or .020 round steel wires are in place.

• For the treatment stages of space closure and overjet reduction. The major tooth movements that occur during these stages of treatment require the rigidity of a rectangular stainless steel wire, as opposed to the flexibility of a heat-activated wire.

In summary, the introduction of heat-activated wires has provided a beneficial substitute for a number of traditional stainless steel wires, and can dramatically improve the efficiency of orthodontic treatment. This substitution is, however, beneficial for initial tooth alignment procedures only. The flexibility of heat-activated wires can actually be detrimental in a number of other clinical situations, as described above. It is important that the orthodontist separates the situations that require archwire flexibility from those in which archwire rigidity is needed.

Fig. 5.35 The patient should be properly instructed on the use of wax and mild analgesics.

CLINICAL PROCEDURES IN LEVELING AND ALIGNING - IMPROVING PATIENT COMFORT AND ACCEPTANCE

At the start of treatment, every effort should be made to ensure that discomfort and inconvenience for patients are minimized. This will normally be their first experience of orthodontic treatment, and there are opportunities for the orthodontic team to make it a good experience.

For many cases, the opening wires will be .016 HANT, but if there are major tooth malalignments, a multistrand .015 wire is preferable. Bends can be introduced into .015 multistrand wires, and these reduce the force applied to the teeth at the outset (Case JN, p. 120 and Case DO, p. 208). The opening wires should not be tied in tightly. Plastic sleeving should be used to make lengthy stretches of archwire more comfortable.

The patient should be given proper instruction on the use of wax and mild analgesics (Fig. 5.35). A good supply of wax should be provided, and it should be made clear that most discomfort will disappear after the first few days.

Archwire ends should be carefully turned in, and particular care is needed with multistrand wires. Steel and HAN'T wire-ends should be flamed and quenched, to allow accurate turning in, and also ease of removal at the first adjustment appointment. Molar hooks should be turned in (Fig. 5.36A).

Much can be made of selecting colored modules at the first visit, for those patients who like the idea of colors. There is a colored module culture among some groups of youngsters (Fig. 5.36(3)! Self-ligating brackets may be an inevitable development in the future, but this will be a concern for many younger patients, who look forward to choosing colors at each visit.

Fig. 5.35 The patient should be properly instructed on the use of wax and mild analgesics.

Fig. 5.36A Molar hooks should be turned in. Fig. 5.36B Many younger patients look forward to choosing coloured modules at each visit.

Fig. 5.36A Molar hooks should be turned in. Fig. 5.36B Many younger patients look forward to choosing coloured modules at each visit.

Fig. 5.37 A follow-up phone call should be made 5-7 days after placement of the initial appliance.

It is correct to have a senior assistant make a follow-up phone call a few days after placement of the initial appliances (Fig. 5.37). This will show that the practice is concerned to know that all is going well, and it is a chance to offer advice and encouragement. During this call, the patient or parent will often raise minor queries, which are important to them, although they 'didn't want to bother the doctor'.

As leveling and alignment progresses, there will be a switch into rectangular 1 IAN'1' wires. This can typically follow directly from the .016 round 11ANT in many cases. The rectangular I IAN 1 wires are most useful and patient-friendly, and the switch is therefore seldom accompanied by discomfort. Any brackets which are wrongly positioned should be repositioned at the rectangular IIANT wire stage, or earlier.

Although there have been many technical advances in orthodontics, there is a continuing need to ensure good patient cooperation, in order to reach treatment goals. Care and consideration from the outset will provide a sound basis for the treatment relationship. This should lead on to better cooperation in many cases.

REFERENCES

1 McLaughlin R P, Bennett J C 1999 An analysis of orthodontic tooth movement - the VTO. Revista Espana Ortodontica 29(2): 10-29

2 McLaughlin R P, Bennett J C 1989 The transition from standard edgewise to preadjusted appliance systems. Journal of Clinical Orthodontics 23: 142-153

3 Robinson S N 1989 An evaluation of the changes in lower incisor position during the initial stages of clinical treatment using a preadjusted edgewise appliance. University of London MSc thesis

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