Nance Appliance, Trans Palatal Arch & Quad Helix

Guided By :Dr D.K. Agarwal (Prof & H.O.D) Dr. Preeti Bhattacharya (Prof)Dr. Ankur Gupta (Reader.)Dr. Juhi Ansar (Senior Lect.)Dr. Ravi Bhandari (Senior Lect.)

Presented By:Asad YusufP.G. Ist yearDepartment of Orthodontic

CONTENT

• Nance appliance• Trance Palatal Arch• Quadhelix Introduction Design Indication Disadvantages

Introduction

• Described by Nance in 1947

• It is simply a Modified maxillary lingual arch that does not contact the anterior teeth, but approximates the slope of anterior palate

The Transpalatal Arch: An Alternative to the Nance Appliance for Space MaintenanceAri Kupietzky,Eli Tal,Pediatr Dent 2007;29:235-8

Design

• .036 SS wire running along palate connecting upper molars.

• The palatal portion incorporates an acrylic button resting on slope of anterior palate that provides resistance to anterior movement of the posterior teeth

Indication

1. Provide anchorage during Alignment & levelling

•By Palatal vault and Cortical anchorage

2.To maintain the position of the second molars where the first molars have been extracted.

3. A modified Nance appliance modified with an anteriorly positioned acrylic button can provide a fixed acrylic flat anterior bite plane for the treatment of anterior deep overbite.

4. Antero Posterior Anchorage in a case of canine retraction

5. Offset Nance button to accommodate the palatally placedlateral incisor with loops to allow adjustment.

Diadvantages

1. Oral hygiene difficulties: Nance appliances result indeterioration of oral hygiene beneath the acrylic plateleading to inflammation of the palate.

2.Poor patient tolerance in comparison to the standard TPA

3.

Nance Appliance induced Pathology

Trance Palatal Arch

Mar. 21, 1922 -Dec. 4, 1992

Robert Ara Goshgarian

INTRODUCTION

Described by Robert Ara Goshgarian in 1972.Owing to the versatile design TPAs can provide passive and active orthodontic forces in all 3 planes

Design

• .036 mm ss wire that goes across the palatal contour from one molar or premolar to contralateral molar or premolar

• Wire soldered to molar band at mesiolingual line angles

• Or by insertion in the lingual sheath in molar band (Wilson or Mershon attachments)

Major indication in mixed dentition is to prevent mesialmigration of upper first molar during transition from seconddeciduous molar to 2nd premolar Graber Vanarsdall Vig 5th ed. Pg 484

Rationale : • When permanent maxillary molars move anteriorly, they rotate

mesiolingually around the large lingual root. • TPA reduces anterior molar movement by coupling the right and

left permanent molars together and, thus, preventing any possibility of rotations.

INDICATION in Transverse Plane

1. Anchorage and arch width stabilization during orthodontic treatments or surgery

2. Retainer after active maxillary expansion

3. To Avoid Molar Tipping

4. Habit breaking appliance

5. Minimally expand dental arches

Transverse Plane :

1.Transverse anchorage and arch width stabilization when aligning palatally impacted maxillary canines

Ref: Baccetti T, Sigler LM, McNamara JA. An RCT on treatment of palatally displaced canines with RME and/or a transpalatal arch. Eur J Orthod 2011; 33: 601−607

2.TPA is also effective as a holding appliance or as a retainer after active maxillary expansion

•

3. TPA & temporary anchorage devices (TADs) combination to correct anterior open bites . TPA is useful in controlling molar tipping during such clinical situation

4. Habit deterrent for persistent thumb and digit-sucking habits. This requires the soldering/welding of a crib to the TPA.

5. Bilateral space maintenance following premature loss of primary molars.

• Prevent loss of Leeway space and potential crowding

of the premolars where extractions of the deciduous molars are planned.

6. TPAs can be used actively to minimally expand dental arches. • Expanded by 3−4 mm to provide a force of around 200 gm.

INDICATION in Anteroposterior PlaneAnteroposterior anchorage :The loop is directed posteriorly if

theTPA is to provide antero-posterior anchorage

GOOD MORNING

Derotation of molars

• Bent-back end of the arch was gripped with pliers and twisted relative to the main arch.

• If the moments on both sides are the same, the Mesio-distal force will be zero.

Moments and forces delivered by transpalatal arches for symmetrical first molar rotation Bengt Ingervall et al

Complications of TPA1. Anchorage loss : Type B Anchorage 2.5 mm of mesial movement of the upper first permanent molars in

TPA while the TADs group provided Absolute anchorage

Feldmann I, Bondemark L. Anchorage capacity of osseointegrated andconventional anchorage systems: a randomized controlled trial. Am J OrthodDentofac Orthop 2008

2.Increase of risk of root resorption : As TPA positions the root of anchor units against The cortical

bone plate

3.Breakage and cementation failure is approximately 2% and 30%, respectively

4.The loop of the TPA can cause palatal trauma

Quad helix• Described by Ricketts in 1975

• Evolved from Coffin’s vulcanite expansion appliance

• He used with great success in the early treatment of those patients with cleft palate in whom the lateral maxillary segments had collapsed behind the premaxillary processes

• Wide range of continuous controlled force

• Frank et al: Forces in the range of 0.5 to 1.5 lbs (200 to 600 g).

• Palatal separation of .92 mm average intermolar expansion was 5.88 mm.

• With the quad helix appliance there was a 6:1 ratiobetween the orthodontic and the orthopedic expansion. The Quad Helix Appliance Ruel W. Bench

Design

Pair of anterior helices

Pair of posterior helices

Anterior bridge.

Palatal bridge Posterior loops should be 4-5mm distal to banded molar but not extending to pterygomandibular raphe

Each of the helical loops adds an about additional 25 mm of wire to the appliance which lightens the force magnitude, rendering a more continuous action due to the greater range of activation provided by the longer wire.

Types

• Custom made: 1 - 0·9mm stainless steel

• Preformed ready type

• Fixed : retained by bands cemented on the permanent first molars.

Adjustment ease with properties of .036 blue ELGILOY(Co,Cr,Ni, Mo, Mn)

Ricketts RM. Bioprogressive technique lecture notes

Action

Fan-like sweeping action :buccally expand and distally rotate the maxillary molar teeth

Jones SP et al: Anterior arms of the appliance affect both the forces produced by the appliance as well as

the force couples operating on the molar teeth. This results from the fact that the anterior arms are a rigid part of the whole appliance.

Importance of fan like action• Parallel expansive force, larger amount of tensile strain was

recorded in the molar region.

• Fan type of expansive force by Quad helix, larger amounts of tensile strain were observed in the canine region.

A reduction occurred as the strain was measured back toward the molar teeth.

T. M. Graber. Jpn. Orthod. So. 42:442-453, 1983

• Parallel expansive force:

Frontal view: maxillary bones were expanded laterally Occlusal view: palate and alveolar processes were expanded

laterally in the molar region.

• Fan type of forcer by quad helix: Palatal and alveolar expansion was noted more in the canine region.

• Since many Class II malocclusions are characterized by maxillary arches that are narrowest in the canine region, it would follow that the fan type of appliance would be most effective.

T. M. Graber. Jpn. Orthod. So. 42: 442-453, 1983

Fan like sweeping action for molar de rotation

• With this appliance,molar derotation is best accomplished by leaving the arms of the quad helix away from the lingual surfaces of the cuspid teeth. As the molar teeth derotate, the arms will come to push against the cuspid teeth and they will then expand together with the rest of the maxillary teeth. The advantage of activating the quad helix appliance in this manner lies in the fact that the maxillary teeth are expanded in a differential manner that "sweeps" them into the ovoid arch form.

The Quad Helix Appliance Ruel W. Bench

Indications

1. Correct cross bites by Upper arch expansion

2. Case needing mild expansion with lack of space for upper laterals

3. Molar Rotation correction

4. Correction of mild class II Malocclusion in which upper arch need to be widened & upper molar rotated distally

5. Class III condition In which upper arch needs to be widened &advanced with class III elastics

6. Habbit breaking aplpliance

Thumb sucking: Palatal bar forward & bended downward

Tongue thrusting: Spikes Soldered on bar & extending downward

7. Unilateral & bilateral cleft palate: The quad helix Expands the buccal segment

8. With face mask

8.extension of .045" wire through the headgear tube of the molar band enables the quad helix appliance to be used in conjunction with a protraction face mask.

Sometimes advantageous to place a bi-helix appliance in the mandibular arch to obtain and maintain a balance in the dimensions of the maxillary and mandibular arches

Practical Application

• Bands are placed on upper second deciduous molar for young case or 1st permanent molar . Particular care is taken to adapt the lingual surface of bands because this is strong purchase area of appliance

• Most appropriate size is selected

• Original cast is used & wire is formed with the finger together with three pong plier to adapt wire according to patients need

•Soldering spot is marked in front of posterior loops depending on the adaptation of arms

•The band is picked up in the tong & approximated as solder is flowed into position

•Desired activation is given

•Appliance is cemented making sure the bands are well seated

Activation

(1) Anterior adjustments produce expansion in the posterior molar area on both sides (2) Lateral adjustment expands and rotates the molar on the activated side. The molar on opposite side is distalized. Activation on both sides causes the rotation & expansion to be on both sides(3) Adjustments to the buccal arm expands the bicuspids and cuspids. When held away from the teeth it allows the molars to rotate. (4) Adjustments through the distal loop gives expansion to buccal arms.

The Quad Helix ApplianceRuel W. Bench

Clinical Management

• Patients should be reviewed on a six-weekly basis for activation.

• Intra Oral adjustment can be done in subsequent visits

• Widening of molars can be activated by pinching between anterior loops.

• Care is taken to give only little activation is of anterior arms and wire is left out of contact with anterior teeth until molar rotation is achieved

Retention after the expansion

• At least three-month retention period

• Achieved expansion should be retained with an upper removable appliance.

• If fixed appliances are being used, the quadhelix can be removed and replaced by TPA.

Disadvantages

• The limited amount of skeletal change & palatal relapse.

• Opening of the bite due to molar buccal tipping.• Outward positioning of upper buccal tooth by an

attempt of nature to upright the root.• Downward Backward appliance posture restrict

tongue functions , so adaptation should be 2-3 mm of palatal tissue

References1.Ricketts : Bio Progressive therapy

2.Influence of’ arch, shape on the transverse eff’cts of transpalatal arches of the Goshgarian type duringapplication ofbuccal root torque G. Baldini and H. ‘U. Luder

3.The Transpalatal Arch: An Alternative to the NanceAppliance for Space MaintenanceAri Kupietzky,Eli Tal,Pediatr Dent 2007;29:235-8

• American Journal of Orthodontics and Dentofacial Orthopedics hl memorianl 561 Volume 103, No. 6 Robert Ara Goshgarian 1922-1992

• Transpalatal, Nance and Lingual Arch Appliances:Clinical Tips and Applications Ortho Update 2015; 8: 92-100

Rationale : When permanent maxillary molars move anteriorly, they rotate mesiolingually around the large lingual root. The space between the buccal and lingual cortical plates becomes narrow anterior to the first molar roots.The large lingual root contacts the lingual plate and acts as a pivot, allowing the 2 buccal roots to rotate mesiolingually.The TPA reduces anterior molar movement by coupling the right and left permanent molars together and, thus, preventing any possibility of rotations.

• In the treatment of narrow restricted maxillary arches,quad helix tip the maxillary molar teeth bucallyTo counter the tipping :buccal root torque is placed in the molar

bands before cementation & leaving the anterior arms of the quad helix away from the lingual surfaces of the cuspid teeth. As the molar teeth derotate, the anterior arms will come to push against the cuspid teeth and they will then expand together with the rest of the maxillary teeth, so the maxillary teeth are expanded in a differential manner that "sweeps" them into the ovoid arch form of the final occlusion.

Expansion and derotation activationplaced in one side of the quad helix, distalizes the molar on the opposite side

Modified to use one entire buccal segment of the arch to a single molar on the opposite side.

A quad helix can be activated to derotate a maxillary molar on one side of the arch provides a distalizing force at the molar on

the opposite side of the same arch.By extending the palatal arms of the appliance on one side, it caninvolve more teeth on that side to act as anchorage in the distalmovement of a single molar on the opposite side of the arch.

VHA has intrusive effect on maxillary molar eruption. Orthodontist must usually guard against further anteriorbite opening during leveling and aligning procedures inpatient with increased lower anterior facial height. An ideal treatment goal for a patient with an acceptablepretreatment overbite would be to at least maintain thesame amount of overlap throughout treatment.

Evaluation of the vertical holding appliance in treatment of high-angle patients MarcDeBerardinis et al :Am J Orthod Dentofacial Orthop 2000;117:700-5)

INDICATION in Vertical planePositioned 4-5 mm away from the palate Fabricated with banded maxillary permanent first molars with connected acrylic button at the sagittal and vertical level of the gingival margin of the molar bands.

Four helices were incorporated into the wire configuration for flexibility.

Nance• Provide anchorage during Alignment & levelling Antero Posterior Anchorage in a case of canine retraction

• To maintain the position of the second molars where the first molars have been extracted.

• A modified Nance appliance modified with an anteriorly positioned acrylic button can provide a fixed acrylic flat anterior bite plane for the treatment of anterior deep overbite.

TPA

1. Anchorage and arch width stabilization during orthodontic treatments or surgery

2. prevent mesial migration of upper first molar during transition from second deciduous molar to 2nd

premolar3 Retainer after active maxillary expansion4. Habit breaking appliance5. Minimally expand dental arches6. VHA

A quad helix can be used to rotate an incisor tooth. In this case, a cleft palate was present