A Multi-Disciplinary Approach to Class III Therapy Using the Delta Force and ALF Appliances in Conjunction with Terminal Arch Extractions
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Fig. 3 Fig. 9 Fig. 10 Fig. 11 Fig. 1 Fig. 2 Fig. 4 Fig. 14 Fig. 12 Fig. 13 A Multi-Disciplinary Approach to Class III Therapy Using The Delta Force and ALF Appliances in Conjunction with Terminal Arch Extractions By J. Wellington (Skip) Truitt, DDS & Livier Carreon-Truitt, DDS Fig. 15 Fig. 5 Fig. 6 Fig. 7 Fig. 16 Fig. 17 Fig. 18 he use of the low friction The panoramic radiograph showed Treatment began by placing an the .020 x .020 arch wire was Delta Force appliance in the third molars to be developing very upper ALF appliance on First Molar replaced every sixty days with a new conjunction with the bio- well in all four quadrants. (Fig. 9) Bands with standard pre-adjusted arch wire of the same type and gauge. compatible forces generated The following was the proposed .022 buccal tubes containing 10° of The treatment objective for this byT the ALF appliance creates a new treatment plan: torque. (Fig. 10) first phase of therapy was to develop approach to treating under-developed Composite ledges were placed on the maxillary arch over the mandibular • Develop the maxilla using a combina- arches. It is now possible to develop tion of ALF and Delta Force appliances. both the left and right maxillary 1st arch. Once this first phase of treat- the size of both the upper or lower bicuspids to secure the crescent wires ment was accomplished therapy could arch and level, align and torque the • Remove the mandibular second molars of the ALF appliance. (Fig. 11) All be initiated on the lower arch. teeth all at the same time. with the view to third molar replacement. three of the anterior omega loops The mandibular second molars were activated. The omega loops were removed and the lower arch was The patient used as an example • Level and align the mandibular arch with for this article was a Hispanic male no torque using the Delta Force appliance. mesial to the first molars were left placed in the Delta Force appliance. 13.4 years of age. His chief passive to function as shock The arch wire gauge was .018 multi- complaint was his unaesthetic smile. • Distalize the lower buccal segments absorbers. (Fig. 12) 4, 5, 6 gradient thermal Niti. The objective Complete orthodontic records were and retract the mandibular incisors. Delta Force brackets were placed was to level and align the dental alveo- on the maxillary teeth through the lar base with no torque maintaining made at his initial appointment. • Burn anchorage within the maxillary (Fig. 1-7) arch using a Forward Pull (Reverse Pull second bicuspids. The starting upper the skeletal Class III compensation. Evaluation of the Bimler Elite Head Gear). arch wire was .020 x .020 beveled (Fig. 16 & 17) 7,8,9,10,11,12 Cephalometric analysis showed the multi-gradient thermal Niti. All of the Once the lower arch was leveled patient to be a skeletal Class III and • Remove the maxillary second molars Delta Force brackets were placed in and aligned .045 molar distalizing with the view to third molar replacement. a skeletal Division II in both the size the minimum ligation configuration. springs and .022 arch wire locks of the maxilla and the position of • Retain the finish case with upper and (Fig. 13, 14 & 15) The ligature elastics were placed mesial to the first Fig. 8 the maxilla. (Fig. 8) 1, 2, 3 lower Spring Hawley retainer. were replaced every four weeks, and molars (Fig. 18) The springs were Spring 2008 Reprinted from the Journal of the American Orthodontic Society www.orthodontics.com Spring 2008 Fig. 19 Fig. 20 Fig. 21 Fig. 28 Fig. 29 Fig. 30 Fig. 31a Fig. 31b Fig. 30c Fig. 22 Fig. 23 Fig. 24 Fig. 25 Fig. 26 activated unilaterally and both first was replaced with a .018 x .025 molars were distal driven. The first steel arch wire. Elastics were worn Fig. 34 molars were then locked in position from the upper first molars to the with new arch wire locks. Reverse Pull Head Gear. These elas- The distalizing springs and arch tics were 5/16”, 8 oz., and were Fig. 27 wire locks were then placed mesial to worn at night only. The objective was the first bicuspids. Both the first and to “burn anchorage” in the upper this four week period. The Delta second bicuspids were bilaterally arch. (Fig. 26 & 27) Force appliance was totally removed driven to contact the first molars. The The final step in the treatment and the patient placed in upper and ligation of the bicuspids was in the was to insure the patient had lower Spring Hawley retainers. (Fig. Fig. 32 29 & 30) minimum configuration reducing the correct cuspid and anterior guid- The retention period was six friction. (Fig. 19, 20 & 21) ance. This was accomplished by months active retention (full-time The mandibular cuspids were next wearing 1/8”, 41/2 oz elastics from wearing except for eating and retracted using 3/16”, 41/2 oz. elas- the upper cuspid pendulum to the hygiene), followed by six months tics from the cuspids to the first lower cuspid and first bicuspid passive retention (night time wear- molars. Note the arch wire lock pendulums in a triangle configura- ing only) sequencing out of the Fig. 35 mesial to the lower first molar and tion. These elastics were worn full retainers one night per month. At the Delta Force rotating wedge on the time except for eating and hygiene the end of the twelve months the distal of the upper cuspid. (Fig. 22) and changed by the patient every patient wore the retainers only once After bilateral cuspid retraction twelve hours. (Fig. 28) a week at night. was fully completed steel ligature The maxillary second molars were The patient was then monitored wire was tied from the first molas then extracted. The upper arch wire on a six month basis until all four through the cuspids and the arch wire was removed and ligature elastics third molars had erupted into occlu- locks removed mesial to the first placed around all of the empty brack- sion. (Fig. 31) molars. A six unit chain elastic was ets in the medium configuration for Active treatment time from the placed cuspid to cuspid to retract the protection. The lower arch wire was initial placement of the upper ALF and lower incisors and correct the dental left in place to act as a retainer. The Delta Force appliances to the begin- midline. (Fig. 23, 24 & 25) occlusion was allowed to function for ning of retention was fourteen months. Once the upper arch development four weeks and re-evaluated. The post retention records demon- was completed the ALF appliance Both the occlusion and the func- strate the long term stability that was was removed. The upper .020 x .020 tion of the Temporal Mandibular obtained by compensating the skele- multi-quadrant thermal Niti arch wire Joints were normal at the end of tal Class III. (Fig. 32 & 38) Fig. 33 Fig. 36 Spring 2008 Reprinted from the Journal of the American Orthodontic Society www.orthodontics.com Spring 2008 Conclusion: understand are the ability to The technique that has just been reduce friction within the bracket, presented using a low friction Delta and being able to begin torquing Force appliance in conjunction with the teeth at the very start of the an ALF appliance reduces the time therapy. This in turn creates a of treatment, but also greatly parallel relationship of the roots increases the stability of the case. and reduces the forces required for The key mechanical principles to sliding mechanics. References: 1 Truitt, J.W. Cephalometrics for Today. 8 Wilson, H.E., Long term observation on FJO 1989, Vol.6(3): 5-11 & 47 the extraction of second permanent molars. Trans Euro-Ortho Soc. 1974: Fig. 37 2 Bastein, G.B., Truitt, J.W. The Bimler 215-221. Cephalometric Analysis. 1985 Ortho Organizers, Inc., San Marcos, California 9 Liddle., D.W., Second molar extraction in orthodontic treatment. Am Journal 3 Truitt, J.W. Advanced Orthopedic and Orthod 1977: 72(6): 597-616. Orthodontic Therapy. 1987. Clinical Foundation of Orthopedics & Orthodon- 10 Orton-Gibbs, S., Crow, V., & Orton, tics. Gainesville, Texas. H.S., Eruption of third molars after the extraction of second permanent molars. 4 James, G.A., Stroken, D., “The Signifi- Part 1: Assessment of third molar posi- cance of Cranial Factors in Diagnosis tion and size. Am Journal Orthod 2001; and Treatment with the Advanced 119(3): 226-238. Lightwire Appliance.” Int. Journal of Orthodontics, 14: 3, pgs. 17-23, 2003. 11 Witzig, J.T. & Spahl, T.J., The Clinical Management of Basic Maxilla Facial 5 Smith, G.H., Ashton, A., ALF Reduces Orthopedic Appliances. Volume II. 1989 Orthodontic Relapse Factor. The Func- PSG Publishing Co., Inc., Littleton, tional Orthodontist, pages 16-20, Nov. Massachusetts. /Dec. 1996. 12 Witzig, J.T. & Spahl, T.J. The Clinical 6 Nordstrom, D., Positive Alveolar and Management of Basic Maxillofacial Gingival Effects of the ALF Appliance. Orthopedic Appliances. Volume II. 1989 The Functional Orthodontist, pages 4-6, PSG Publishing Co., Inc., Littleton, Nov. /Dec. 1996. Massachusetts. 7 Wilson, H.E., The extraction of second molars as a therapeutic measure. Trans. Fig. 38 Euro-Ortho Soc. 1966: 141-145. Dr. J. Wellington ( Skip ) Truitt Dr. Truitt received a Bachelor of Science degree from Texas Christian University and his Doctorate of Dental Surgery from Baylor University. He has maintained a private dental practice in Gainesville, Texas, since 1967. Dr. Truitt is also a consultant to other private medical and dental practices in Australia, Thailand, Singapore, South Africa, Mexico, Ireland, Norway, Germany, the United Kingdom, Canada and the United States.