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Author Topic: Can't Close the extraction spaces...  (Read 1979 times)
realdentistry
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« on: September 02, 2011, 09:10:20 PM »



After following the recipe precisely, I'm having difficulty closing the extraction sites. THe cuspids are in class I and the molars are in class I. I'm beginning to wonder if the initial diagnosis was correct to extract teeth.

Any dieas on how to salvage this case?

More pics:







Thanks!
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LAKA
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« Reply #1 on: September 02, 2011, 10:21:48 PM »

I find that too much force activation and fricition(in sliding mechanics) are the main culprits in delayed space closure.
I see an overactivated KH LHS. Why on KH?
Lower spaces are closing well. Remember 1mm/month. As this is a frictionless case, wire binding is not an issue. I would reduce force levels either with T loop or go to sliding mechanics. Risk here is you will lose Class 1 LHS. Make sure you have sufficient overjet before activating the closing loop. Also heavy biters (brachycephalic) will take longer for space closure-consider temporaray bite opening.

LAKA
« Last Edit: September 02, 2011, 10:40:25 PM by LAKA » Logged
realdentistry
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« Reply #2 on: September 02, 2011, 10:36:36 PM »

How do I achieve temporary bite opening? And what are the alternatives if there is too much friction of the archwire with the brackets? Besides, how do I check for friction?

Thanks by the way for the input and quick response!
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LAKA
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« Reply #3 on: September 02, 2011, 11:19:21 PM »

Remove the cinhbacks and see if the wire slides easily into and out of all the bracket slots and buccal tubes. If it doesn't stop force activation and may need to go through wire progression to level the arches before recommencing activation. But this is more applicable with sliding mechanics. In your case with closing loop mechanics friction is not as much of an issue. Force level activation is. Too much force will bring tooth movement to a halt with potential anchorage loss. I would reduce force to 1mm activation on T loops as recommended and try opening bite either with occlusal comp splints on lower 7's and 6's or upper palatal acrylic coverage. Since 7's not bracketed must splint these teeth as well.

LAKA
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CharlieK
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« Reply #4 on: September 05, 2011, 11:25:35 AM »

With the KH legs opened that far I would agree you have too much force.....  You say you are following the recipe?   Why is there chain from the 6-4?   If you do this you will get space opening b/w the 3-4  as the anchorage of the 6 will win out.  To do that I would lig lace 4-4  ...but  that us not  what you need here.....   
 I actually see some class 2 canine left and rt  and some Class 3  molar left and right  (a little more  than "super class1").... from here I would suggest NiTi coil closure step 2 upper Kh - 6  +  class 2 elastic U3-L6  (left  and  right).  When canines are true class 1   goto step 2  UKH-U6  and  step 3 LKH-L6.  If  canine gets out of class 1   go back to class 2 elastic U3-L6 .....  What I have described is a "slow way"   but will keep you in control.
 I am presuming that you have Li Upper?

You are almost there and you have done a nice job...all spaces are closing quite symmetrically.  You  have  more space than OJ left  so that is why you can start to "burn molar anchorage"  which is what step 3 activation will do....
Hope this helps
Regards
CharlieK
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DMcGann
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« Reply #5 on: September 06, 2011, 04:16:25 AM »

realdentistry,
   Whenever you are having a problem (in this case slower space closure than you 'expect'), then you need to take a progress ceph/pano and see where you are...get information.  The information you need is if the incisors are at the retraction limit of the 19x25 + whatever bracket torque you have on the incisors upper and lower.
   I am guessing that the incisors are at the retraction limit...and with the VERY HEAVY force you are applying by activating the KH loops that much (my guess is 400+grams per side), the only thing that can really move is the molar moving forward.  If only one side is moving, then space closure is slower.
   Chain is a very poor force to close extraction spaces with.  starts out heavy force and rapidly decays.  The force of the chain added to the massive force of the KH loop activation and I am surprised anything moves. Too much force and the teeth stop moving. you are close to this much force.
   HOW you close the extraction space should already be definited by your dental vto of the treatment decision. Then you know if you want to move the molars forward or the incisors back...which you want to do determines what force you use....sorry to add so many questions to your question. LOL
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CharlieK
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« Reply #6 on: September 07, 2011, 09:49:16 AM »

Hi Real dentistry,   
I find myself looking at your excellent pictures today and realise that I have missed a couple of *very important points* in my earlier response.
Firstly:  What plan # are you following?   I should not have replied in all reality as I do not really know what you are trying to do with the incisors!!!!
Secondly:  I would like to know what plan # you are following since I didn't realise we do cinch back on any KH.  In POS we only do cinch back on T loops.....  I am possibly wrong so I would like to know that now!
Thirdly:   I see deep bite and Upper incisors a little detorqued  ( are the brackets Li/La in this case?).......  If you continue you will probably not get to correct OB  and OJ in this case............  at least not without increasing the risk of TMJ symptoms.

You would be best to go for a T loop and place a gable band (20 degrees) to increase the torque and lessen the deep bite....BUT it all depends on what you are trying to do with the incisors............  Back to what Plan# are you following?

Regards
CharlieK
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Marta
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« Reply #7 on: September 07, 2011, 02:18:44 PM »

Ups!.........
Hi Real dentistry:

First of all let me tell you how wonderful is to SEE a photo when you are nearly 50 and can NOT see anything without your glasses. I feel young again. GREAT photos doc, I wish were mine.....

May I point out some details............. hope you do not mind, LAKA + CHARLIE-K.

“THe cuspids are in class I and the molars are in class I”

Have no option but to start with a very good story about CL I (this is from the VERY FAMOUS DR. JEFFERY TAYLOR that you all know,.............I have to worn you to be CAREFUL cause he is going to teach you ALL..........SO WELL and he is going to make you love ortho SO MUCH....that your life will never be the same). Am I right David, Ralph, Elena, Mike, Glenn, etc, etc, etc........ Huh?? DR. Taylor you can yell at me if I do not write it correctly...........am sorry.......a copy is NEVER as good quality as the original:

“You cannot have “ALMOST” Cl I, and it is like being pregnant, you are or you are not and the option “almost”.......... is no way possible”.

Look always very close for that cuspid CL I, and if you do NOT have it or lose it, while mechanics, go for it and THEN.... you start to close spaces or continue to close spaces......Marta Smiley
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realdentistry
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« Reply #8 on: October 19, 2011, 08:17:40 PM »

I'm still unable to close the spaces. I don't know what to do! I need help!!!!
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Mala
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« Reply #9 on: October 20, 2011, 05:16:56 AM »

Real Dentistry, did you change the Keyhole loops to T loops yet? As Charlie pointed out,  I am curious to see what your treatment plan is.. I am seeing the loss of incisor torque here already..If you changed the wire  to Tloops then by adding closing coil you can close the spaces(also by cinching the Tloops)...again, what is the treatment plan?? Sorry, can`t answer your question without asking you the questions...
Mala
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Unsalted
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« Reply #10 on: October 20, 2011, 11:21:26 PM »

All these things have been said already but first of all...

 RELAX  Grin.  Your case looks Great!  You're a good dentist.  Everybody likes you.  You're highly trained and will be super successful in all you do  Wink

Have said that (and after your deep deep breath and total relaxation) 1. too much force.  Needs whatever was prescribed in your treatment plan.  Most likely t-loops activated 1mm (which doesn't look like much) and niti closed coils.  2. If your facial profile and incisor torque are where you want it, then you're trying to burn anchorage at this point, and that takes time.  Time.  Time. Time. Time.  Worrying and Time do not go well together. 3. If your NOT trying to burn anchorage (and I can see some things that would make you think that... namely the space between the laterals and canines) then you may need to revisit the topic of gable bending (which is most likely in your treatment plan) for the purposes of gaining clearance for incisor retraction.  This of course is done only after getting the cuspids back where you want them (which they are not in my opinion). 

Does any of that make sense?

Peace and relaxation!

p.s. I've never seen keyholes activated... and especially not on the lower arch!  En masse retraction is generally an upper arch kind of thing.
« Last Edit: October 20, 2011, 11:23:31 PM by Unsalted » Logged

Respecfully, as always,
Dr Chris Sortman
Mike
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« Reply #11 on: October 22, 2011, 10:31:37 AM »

Guys please tell me honestly whether I overlook something :
I see a normal situation in an extr.case at the end of space closure.I see canines cl.I , molars cl.I or slightly cl.III remaining spaces in extr. sites. In the old POS book the patient would have upper + lower intra ( KH - 6 ) as long as this relationship remains. In the newer book you could use coils with step 3 activation as long as this relationship remains. I don´t see a problem that justifies that long discussion. But again : let me know if I overlook something.
Regards Mike
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Unsalted
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« Reply #12 on: October 22, 2011, 11:36:30 PM »

That's sort of what I was saying... Hence my whole relax comment.

The only thing that concerns me is the misunderstanding of what keyhole archwires are for.  They are not for activating like that... (as you know mike). 

The other thing that bothers me is why real dentistry is freaking out a bit.  That, in and of itself, can be a problem!

There are some technical discussions to be had here, but they are not significant enough to keep me awake at night.
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Respecfully, as always,
Dr Chris Sortman
gtakenaga
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« Reply #13 on: October 22, 2011, 11:59:18 PM »

I see this problem very simply
[ Attachment: You are not allowed to view attachments ]

step 2 force = 150-170 gm, ie 12mm Nitie closed coil activated 5mm
step 3 force = 200-230 gm, ie 12mm Nitie closed coil activated 9mm
step 4 force = 250-280 gm, ie 12mm Nitie closed coil activated 11mm
WITHIN OPTIMUM TOOTH MOVEMENT AMT OF FORCE

sea lions 6 oz 1/4" activated 25mm = 8 oz = 240 gm
WITHIN OPTIMUM TOOTH MOVEMENT AMT OF FORCE

chains day 1 = 20 oz. = 600 gm but decays quickly to 7.5 oz after 1 week
LOTS OF INITIAL FORCE BUT QUICKLY DECAYS TO OPTIMUM TOOTH MOVEMENT AMT OF FORCE

T loop 1mm activation = 8 oz = 230 gm, 2mm activation = 18 oz = 740gm
GUESS WHY WE RECOMMEND ONLY 1MM ACTIVATION??

KH loop 1mm activation = +20 oz = +600 gm, 1/2mm activation = 16 oz = 280 gm
HOWEVER 2-4MM KH LOOP ACTIVATION IS OFF THE SCALE FOR OPTIMUM TOOTH MOVEMENT.
GUESS WHY WE DO NOT RECOMMEND ANY KH LOOP ACTIVATION!!!!!!!
_________________________________________________________________
In Addendum:

Realdentistry,

You could argue that KH loop activated 1/2mm is within optimum biological forces, but 1mm and greater is not. Besides even if you could activate 1/2mm (which is almost impossible), the maximum amount of movement will only be 1/2mm in 4 weeks. With T loops at least you can activate 1mm and still be within optimum biological forces and get more tooth movement to boot (T loops have more wire than KH loops therefore has more wire flexibility). The other problem with KH loop activation is that because it is next to impossible to activate only 1/2mm on KH loops, there is the tendency to add excessive forces. If you activated too much force the first time and there is little or no tooth movement due to excessive forces, then you will tend to add on top of the initial excessive forces compounding the problem. In other words excessive forces = little or no tooth movement, hence your cry for help "Can't Close the extraction spaces".

I recommend cutting off the cinchbacks and letting the forces dissipate for 2-4 weeks. Then restart your mechanics keeping your forces within the range for "Optimal tooth movement".

In the meantime, while you are waiting for the forces to dissipate, study your title slides on anchorage and mechanic forces to decide how you are going to obtain class I, maintain class I, and close remaining extraction space. Seminar 17 is a good place to start.
www.sierradentalcare.com
« Last Edit: October 23, 2011, 01:24:04 AM by gtakenaga » Logged
Mike
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« Reply #14 on: October 23, 2011, 01:50:59 PM »

What can we ( esp. realdentistry ) learn from question and discussion :
- if you want to do ortho, you gotta be patient
- playing soccer means "the harder you kick - the faster and longer the ball flies" ortho is different. It works best with small constant force
- there is a long list of POS treatment plan, and unless you´re an expert there is no need to "modify" them or invent your personal mechanics
- the system looses predictability when you don´t follow the rules.
The case shown is not special, it´s normal ortho. What makes it special is the attempt to speed it up. You didn´t ruin the case, follow the instructions, learn from it and try to stay closer to the treatment plans until you got more experience. Don´t worry , most of us ( including me of course ) had to learn that.
Regards Mike
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