It include proximal stripping, Diagnostic aids, advantages, disadvantages, periodontal consideration, procedure for proximal stripping. Expansion, extraction, Distalization in detail as method of gaining space, Extra-oral, Intra-oral method for gaining space. uprighting, derotation of posterior teeth. proclination of anterior teeth.

1. Methods of gaining space
Dr. Shweta A. Kolhe
BDS.MDS (Orthodontist). PhD Scholar.
Senior Lecturer at V.Y.W.S. Dental College & Hospital,
Amravati.

2. Methods of space gaining
Proximal
stripping
Expansion Extraction Distalization
Uprighting of
molars
Derotation of
posterior
teeth
Proclination of
anteriors

3. Need for gaining space?
Correction of
many
malocclusion
Move teeth in
to ideal
position
Correction of
crowding
Retraction of
proclined teeth
Leveling a steep
curve of spee
Derotation of
anterior teeth
Correction of
unstable molar
relation.

4. Proximal Stripping
• A method by which the proximal surfaces of the teeth are sliced in order
to reduce the mesio-distal width of the teeth.
• Also called as reproximation, slenderization, disking and proximal slicing.
• Location- Lower anterior
- Upper anterior
- Buccal segments of the upper and lower arches.

5. Indications of proximal stripping
• Minimal i.e. 0-2.5 mm space required.
• If Bolton’s analysis show mild tooth material excess in either of the arches.
• Aid to retention in lower anterior region.
• Cases where individual tooth sizes prevent a Class I molar & canine
relationship.
• To obtain a more favorable overbite an overjet.

6. Contraindications of proximal stripping
• In young patients, as they possess large pulp chamber, which increases the risk
of pulpal exposure.
• Patients who are susceptible to caries or those who have a high caries index.
• Avoided on small teeth with enamel hypoplasia.
• Patients who refuse to accept slenderization as a treatment option
(informed consent is imperative)
• Patients with poor oral hygiene and high bacterial plaque index.

7. Diagnostic aids for proximal stripping
• Arch Perimeter analysis / Carey’s analysis –
Tooth material excess of 0-2.5 mm over the arch length is a diagnostic
criteria favouring reproximation.
• Bolton’s analysis-
Minimal inter-arch tooth material discrepancy can also be corrected.
• Intra-oral periapical radiographs-
IOPA gives idea of the enamel thickness & a rough estimate of the amount
of the enamel that can be removed from the proximal surface, without
exposure of the pulp chamber.

8. Amount of proximal stripping
• Not more than 50% of the enamel thickness should be reduced by
proximal stripping.
• Whenever reproximation is undertaken in a segment of an arch, it is
advisable to equally distribute them over all the teeth.
• According to Sheridan 0.4 mm reduction per each surface of posterior
teeth and 0.25 mm in the anterior teeth can be performed thereby gaining
in total about 8.9 mm.

9. Instruments used for proximal stripping
• Diamond interproximal strips –
- very thin strips (0.08 mm)
- Made of surgical grade stainless steel with
electrolytically bonded diamonds.
- Resist stretching or breaking.
- Autoclavable and reusable.
- Strip holders are available that holds these strips.
- Abrasive strips are available in either single or double
sided coating and come in three grades i.e. fine,
medium and coarse.
- Perforated strips are available that allow optimal
visibility and minimize clogging.

11. Procedure for proximal stripping

12. Advantages of proximal stripping
1. In borderline cases where space requirement is minimal extraction can
be avoided because of potential consequences of extraction:
 Difficulties in completing space closer.
Difficulties in paralleling the roots next to extraction sites.
Need for greater anchorage reinforcement than in slenderization cases.
Possibility of space re-opening.
Unwanted profile changes related to retroclining incisors hence closing
extraction spaces.
2. More favorable overbite and overjet can be established.
3. More stable result can be obtained by broadening the contact area.

13. Disadvantages of proximal stripping
1. The stripping procedure creates roughened proximal surface that
attracts plaque.
2. Caries susceptibility is increased as part of the enamel is removed,
leaving behind a roughened area.
3. Patients may experience sensitivity of teeth.
4. Improper procedure can result in alteration of morphology of the teeth.
5. Loss of contact between adjacent teeth may result in food impaction.

14. Periodontal considerations of proximal stripping
• Compressing the interradicular tissue by closure of space
following slenderization could be a precursor to periodontal
distress.
• But recent studies show no increase in pocket depth,
recession or bone loss after reproximation.

15. 1. Pre- treatment 2. Comprehensive panning 3. Access to the interproximal areas
4. Interproximal enamel removal 5. Finishing and polishing of enamel surfaces 6. Topical fluoride application
Sequence of clinical steps for proximal stripping

16. Sequence of clinical steps for proximal stripping
• Comprehensive planning -
Study mode measurements can determine the required amount of stripping.
Ideally a diagnostic set-up will supplement treatment planning and
visualization the final position and morphology of teeth. The use of
calibrated radiographic images to determine the exact amount of enamel
that can be removed may be done.

17. • Access to the interproximal areas –
Visibility and mechanical access to the proximal surfaces is required for
efficient stripping of the interproximal area. This can be aided by the
initial phase of levelling and aligning and correction of rotations. In
addition mechanical separation of the teeth can be a valuable aid.

18. • Interproximal enamel removal –
Interproximal enamel reduction is performed by either manual or mechanical
methods. This can involve use of metallic strip system, diamond discs or by
use of long burs. The orthodontist is generally advised to be conservative in
initiating stripping procedures. Small enamel amounts should be ground
symmetrically from all contact areas before maximum acceptable removal
per site is reached.

19. • Finishing and polishing of enamel surfaces –
Sof-lex disks and finishing diamond burs can be used to finish and contour
the surfaces that have been stripped.
• Topical fluoride application –
Topical fluoride application is recommended to help in remineralization of
the abraded proximal surfaces. It is prudent to prescribe a fluoride gel. In
case of sensitivity following senderization fluoride containing mouth rinse
can be prescribed.

20. Fluoride application
• The increased caries susceptibility after slenderization is
managed by a comprehensive fluoride programme following
the procedure.

21. Expansion As A Method Of Gaining Space
• Expansion is one of the non-invasive methods of gaining
space.
• Undertaken in patients having constricted maxillary arch or
in patients with unilateral or bilateral cross bite.
• Expansion can be skeletal or dento-alveolar.
• Skeletal expansion involves splitting of the mid-palatal
suture.
• Dento-alveolar expansion produces a dental expansion
with no skeletal change.
• Various appliances- jackscrew or springs.

23. Extraction As A Method Of Gaining Space
• Extraction that is undertaken as a part of orthodontic treatment is called
therapeutic extraction.
• Premolars are the most frequently extracted teeth as part of orthodontic
treatment.
• Extraction of molars or lower incisors are done during orthodontic therapy.
• Extraction of canines and upper incisors is usually avoided.
• Extraction provide space for correction of crowding / proclination.

25. • One of the popular technique of recent time is distalization of
molars.
• This technique is aimed at moving the molars in a distal direction
to gain space.
• This approach is becoming popular due to the fact that extractions
can be avoided.
• Distalization of maxillary molars- significant value in the treatment
of mid to moderate class II molar relation associated with a normal
mandible.
• Ideal timing for distalization – mixed dentition period prior to the
eruption of the second permanent molars.
Distalization

26. Indications for distalization-
• Best done in moderate maxillary skeletal / dento-alveolar protrusion.
• Moderate arch-length deficiencies.
• When extraction of the maxillary teeth is not indicated.
Contraindication for distalization-
• In severe protrusive profiles and severe incisor proclination.
• In case of high mandibular plane angle and anterior open bite.
• Severe crowding (more then 6mm)
• Patients with insufficient seating of the Nance button because of reduced
palatal vault inclination.

27. • Distalization can be brought about by following methods-
1. Extra – oral methods
2. Intra – oral methods
Extra – oral methods-
• Headgears deriving anchorage from the cervical or cranial region.
• Headgear assembly consists of a face bow that is made of an inner and an
outer bow.

28. • The inner bow is fixed to buccal tubes present on the molars.
• The outer bow is attached to the extra- oral head cap or neck strap.
• Use of extra-oral forces for distalization has following disadvantages:
1. Patients co-operation is essential for timely wear of the appliance.
2. The appliances are usually not worn continuously.
3. Intermittent in there action resulting in prolonged treatment time.

30. Intra-oral methods:
• In order to overcome drawback of extra-oral appliance intra-oral appliances were introduced.
• Intra-oral appliances are fixed on to the teeth and Produce a continuous effect.
e.g. 1. Sagittal appliance
2. Pendulum appliance-
a. Hilgers pendex
b. T- Rex appliance
c. The Hilgers PhD appliance
3. Distalization using intra-oral magnets
4. use of open coil springs to distalize molars
5. Jones Jig
6. Distal Jet
7. ACCO appliance
8. The fast Back appliance
9. Transpalatal Arch for distalization
10. Use of Fixed Functional Appliances for Molar Distalization.

31. Sagittal expansion appliance
• Removable appliances incorporating jackscrews.
• Appliance consist of split acrylic plate joined together by a jackscrew.
• Acrylic plate is sectioned in such a way that the tooth that is to be
distalized is isolated, while rest of arch is used for the purpose of
anchorage.
• Appliances are retained using Adams clasps on molars and premolars.
• Used both in the upper and lower arches.
• Jackscrews are positioned in such a way that their long axis is parallel
to the occlusal plane as well as the buccal surface of the molars.
• Most effectively done with extraction of second molar.
• Use: 1. Correct crowding
2. Used for distalization of only one tooth at a time to avoid
undue strain on anchorage.

32. Pendulum appliance
Pendulum Appliance
Hilgers pendex
T-Rex Appliance The Hilgers PhD Appliance
• Introduced by Hilgers
• Modified Nance button
for purpose of
anchorage.
• Consists of a stainless
steel or TMA wire.
• A helix, the distal end of
which is inserted into a
sleeve on the palatal
aspect of the molars to
be distalized.
• Same components and
function as pendulum
appliance
• Midline appliance is
added
• Expansion can be
initiated post
distalization or
simultaneously with
distalization.
• Modified pendulum
appliance with midine
screw for expansion.
• Also includes locking
wires which are
soldered to mesial
aspects of molar
bands.
• Expansion using a
hygienic rapid maillary
expansion screw.
• Goshgarian locks are
soldered underneath
the body of the screw
which engages the
TMA pendulum springs.

33. Distalization using intra-oral magnets
• Intra-oral repelling magnets can e use to distalize
molars.
• Repelling magnets placed on the molar to be
distalized and the tooth anterior to it.
• Anterior anchorage can e reinforced using a Nance
holding arch.
• Consists of repelling magnets that slide over a thick
wire that inserts into the molar tube on buccal
aspect of the molar to be distalized.
• A sliding yoke that is ligated to the second
premolar is used to bring the repelling magnets
together thereby applying a distal force on the
molar.

34. Use of open coil spring to distalize molars
• Open coil nickel titanium spring compressed between the molar and
the anterior segment.
• Anterior anchorage is reinforced by use of a Nance button that rests
against the anterior part of the palate.

35. Jones jig • The Jones Jig is a simple, but effective
appliance for distalizing upper molars.
• It may be used for bilateral or unilateral
corrections.
• The mainframe is inserted into the buccal
tube and ligated.
• The super-elastic coil spring is slid onto the
mainframe wire and secured by the sliding
eyelet tube.
• Force is obtained by compressing the spring
and ligating the eyelet to the bicuspid
bracket.
• Anchorage support is provided with a Nance
appliance.

36. The Distal Jet
• A lingual distalization appliance.
• The line of force running close to the center of
resistance of the molar.
• Consist of bilateral piston and tube arrangement, with
tube embedded in a modified acrylic Nance palatal
button.
• Compressing coil spring generates a distally directed
force.
• Advantage:
- Less distal tipping
- Easily converted into a Nance Holding arch to maintain
distalized molar position

37. ACCO appliance
• The acrylic cervical occipital appliance (ACCO) Introduced by
Dr. Herbert I. Margolis.
• Modification of the Hawley retainer, with addition of finger
springs mesial to the maxillary molars and combining the use
of a headgear.
• Anteriorly there is a labial bow over the incisors which can be
embedded in acrylic for optimum retention.
• Adam clasps on first premolars for retention.
• Finger spring is placed mesial to first molar to provide the
distal tipping force.
• Acrylic palatal section for retention also as anterior bite plane
to disocclude posterior dentition and allow movement of
molar.
• Bodily molar distalization with extra-oral traction or loops on
the labial bow.

38. The Fast Back Appliance
• Appliance consist of a Nance palatal button for
anchorage.
• Two special screw, one on either side with anterior
part embedded in acrylic.
• A small tube of 1.1 mm diameter is soldered onto
palatal surface of the bands on molars to be
distalized.
• An open coil spring is added to the arm as it slide
into the tube and delivered required force.

39. Transpalatal arch for distalization
• Transpalatal arch or TPA spans the paate from the
palatal aspect of one molar to the opposite molar.
• Use
- for anchorage
-Correction of molar rotation
- Unilateral distalization of molar.

40. Fixed functional appliances for molar distalization
• Fixed functional appliance such as Herbst
appliance and Jasper jumper that have been
used in the correction of class II malocclusion
have been found to produce a certain amount of
distal movement of the maxillary molar.

41. UPRIGHTING OF MOLARS
• Premature loss of a second deciduous
molar or extraction of a second premolar
can cause mesial tipping of the first
permanent molar.
• Mesially tipped molars occupies more
space than an upright molar.
• Molars can be uprighted using molar
uprighting springs or some form of space
regainer.

42. Derotation of posterior teeth
• Rotated posterior teeth occupies more space than normal spaced teeth.
• Derotation is best achieved with fixed appliances by incorporating springs
or elastics using a force couple.

43. PROCLINATION OF ANTERIOR TEETH
• Proclination of a retruded anterior results in gain of arch length.
• Indicated –
1. where teeth are retroclined.
2. Where protracting the anteriors will not affect the soft tissue profile
of the patients.

44. This Photo by Unknown Author is licensed under CC BY-NC