LEVELING AND ALIGNING

Leveling and alignment

The straight wire appliance has allowed orthodontists to treat patients effectively.
more efficient, with excellent results. Many of the procedures used with
the standard cantilever arch device has been effectively transferred to the
straight arc device.
Leveling and aligning is the fundamental objective of orthodontics during the initial phase of
treatment. A necessary stage before correcting major aspects of malocclusion,
such as the reduction of horizontal transfer, or closure of spaces.
A definition of this first stage of treatment would be leveling and
Alignment is all the dental movements necessary
Manuel Adriazola P. to achieve the fit.
passive of a rectangular wire of 0.019 x 0.025" in diameter, shaped like an arc,
in a Straight Arch bracket system with a 0.022” slot, properly adapted.
Anchor control
The most significant movements of the teeth, supported by various methods of
anchoring control is achieved after leveling and alignment are completed
carried out.
It has been found that leveling and aligning produces certain dental movements.
unwanted and if not controlled, the malocclusion worsens, increasing the time and
the treatment effort, for that anchor is needed which are all the
maneuvers used to restrict unwanted movements during this initial phase
of treatment.
Long-term and short-term goals
The leveling and alignment against long-term treatment goals must be considered.
short term.
Manuel Adriazola P.
Thus, the short-term goals in the initial months of treatment are for
achieve leveling and alignment with a passive rectangular arch.
The long-term objectives, to be achieved at the end of the treatment, will be for
achieve an optimal occlusal relationship, correctly in the 3 planes of space and these
related to a good facial profile.
Experience and practice have shown that attempts to achieve objectives
in the short term very quickly, causes unwanted movements. These
make long-term goals harder to achieve,
increasing the treatment time.

Manuel Adriazola P.

Typical dental movements at the beginning of leveling and alignment with appliances before-
adjusted. Movements of the root in X, Y, and Z, which would not have occurred with brackets of
standard corner arch.
Manuel Adriazola P.
Control in the three planes
The anchorage controls certain undesirable dental movements while it is being performed.
other movements to establish an optimal position of the teeth at the end
of the treatment. This control can be observed in the three planes: sagittal, vertical and
transversal. However, it is necessary for these three planes to be related, and the
Error when trying to control one plane can cause problems with another.
In the horizontal plane, anchoring control is used to achieve a position
correct antero-posterior positioning of the teeth in relation to the facial profile at the end of the
treatment. This often involves the limitation of mesial movement of the
posterior teeth while promoting the distal movement of the anterior teeth.
For example, in a class II-1 malocclusion caseP.with maximum anchorage, it refers to
Manuel Adriazola
that treatment where no movement of the segments is allowed
posterior towards mesial, while preparing for a maximum retraction of the sector
antero-superior.

Horizontal control of the anchoring, at the beginning of treatment later promotes correction
of the horizontal transfer, and helps achieve a correct anteroposterior position of the
tooth with the profile.
In the vertical plane, the control of anchorage involves the need to try to limit the
vertical skeletal and dental development in the posterior segments (such as the
high angle cases) and sometimes try to limit the vertical eruption of the segments
previous ones, or even to instruct these segments.
Manuel Adriazola P.
 Manuel Adriazola P.

Vertical control of immediate anchoring is important, especially in cases of

high angle. The posterior vertical control of the molars can influence the height of
lower third of the face, at the end of the treatment. If the molars extrude the height of
the face will tend to increase and the pogonion is directed distally. The control
anterior vertical is useful in the immediate correction of problems of the
overbite. This can also help to determine the occlusal plane in relation to
the lip line at the end of the treatment, which can be important in maintenance
from Class II - 2, and also in cases of gummy smile.
In the lateral plane, anchor control often involves the maintenance of
the movements achieved by the expansion procedures.

Preference should be given to full body movement and not to inclination.

Muscle factors will cause a relapse of indiscriminate expansion in most cases.
of the cases.

o
Anchoring in the horizontal plane Control of the previous segments
The first difference observed between the standard cantilever arch device and the
straight arch device, it is the tendency of the anterior teeth to tilt towards
vestibular during the initial phase of leveling and aligning. This is due to the
built-in inclination in the previous brackets, and it is greater in the upper arch,
where there is more incline in the design.

Manuel Adriazola P.

Effect of initial wires on anterior teeth with straight wire brackets:

the inclination incorporated in the previous brackets, vestibularizes
teeth.
Attempts have been made to eliminate or reduce this effect by linking segments.
previous to the later ones, generally with elastic forces. However, this
it created a greater demand for anchoring control during this initial stage of
treatment.
It has also been observed that if the elastic forces are greater than the forces of
Wire leveling causes a tendency for the anterior teeth to tilt.
and rotate distally, increasing the curve of Spee and deepening the bite.
This is more evident mainly in cases of extraction.

o
 Manuel Adriazola P.

The effects of elastic forces, applied to the canines at the beginning of the treatment.
with extraction: Inclination towards the extraction site; Mouth opening
in the regions of the premolars; Greater depth of the anterior bite.
There are two ways to reduce this effect. The method chosen by Andrews, and more
Late by Roth, it was to maintain levels of forces and mechanical treatments
identical and introduce features in bracket systems, to avoid the
unwanted movements. Extra torque was placed on the brackets of the incisors and
anti-tilt and anti-rotation characteristics in the canine brackets
premolars and molars. These movements in the "extraction" brackets some of
which were later grouped to form the final recipe of the device of
Roth. The arms of power were increased to some brackets to bring the
forces as close as possible to the centroid point of each tooth.
A new strength level system could only be developed by observing
the effects of various forces in many cases. Initially, forces were used
minimum elastics, but it was observed that, regardless of the bracket system
there was a tendency for inclination and distal rotation of the anterior teeth, and the
mesial inclination and rotation of the posterior teeth. Therefore, the use of force
the elastic was discarded, with the distal anchors being introduced into the molars.

o
 Manuel Adriazola P.

Distal ties (conjugated); 0.010” binding wires used in a case of

extraction to prevent the inclination towards the vestibular of the canines during the
leveling and alignment. The purpose of the distal ties (conjugated) is to prevent
that the canines tilt mesially, but it was observed that those wires of
Ligatures are an effective method for distalizing canines without causing tipping.
The mechanism of this movement is that it produces a slight initial tilt of the
canines against the alveolar crest, followed by a repositioning period of the
root and crown.. With elastic forces, this time of repositioning does not occur,
due to the presence of a continuous tilting force, while with the
distal bindings (conjugated), if this repositioning occurs by applying
only a slight initial force and it does not continue. The distal bend of the wire, in the
last molar, it also helps to decrease the inclination towards the buccal of the
incisors.

Effect of distal ties (conjugated) on canines during the first phase of

treatment (leveling and alignment).
Manuel Adriazola P.
 Manuel Adriazola P.

Bends at the distal of the molar tubes, which help control the inclination of the
incisors.
In summary, the initial methods of controlling the anterior anchorage, during leveling.
and alignment includes the use of distal ties to reduce inclination
towards the mesial of the canines, and to effectively retract when indicated, along with
the distal bends of the arch to decrease the inclination of the incisors towards
distal bindings (conjugated) consistently show
clinical advantages.

I
/

1.78 |

In Robinson's (1989) study, in the group without distal tethering (conjugated), the
lower molars moved on average 1.53mm towards the mesial, and the
Manuel Adriazola P.
lower incisors on average 1.47mm. In the group of distal ties
(conjugated), the molars moved slowly towards mesial, only a little
more than in the group without distal restraints (conjugated), on average 1.76mm. Without
embargo, the lower incisors moved distally on average 1.0mm, which
indicated good support for the control of the anchoring of the distal ties (conjugated).
Control of the posterior segments: upper arch
In certain cases, it is necessary for the later segments to be limited in their
mesial movement, maintaining its position, to allow for the segments
previous ones are correctly positioned. The requirements for anchor control
posterior, are usually larger in the upper arch than in the lower arch, due to
to five main factors: Manuel Adriazola P.
The upper anterior segment has longer teeth than the anterior segment.
inferior.
The upper anterior brackets have a greater inclination than the anterior brackets.
inferior.
The upper incisors require more torque control and body movement than the
lower incisors; which only require distal inclination or verticalization.
The upper molars generally move faster mesially than the lower ones.
lower molars.
There are more typical cases of class II malocclusion than class III.
Due to these factors, an extrabucal force is usually the most
effective for achieving control of the posterior anchor in the upper arch. McLaughlin is
in favor of a combined extraoral (occipital traction and cervical traction), in the
majority of cases. The strength levels used for the combined extraoral are
from 150-250g for occipital traction and 100-150g for cervical traction. These
force values allow a
Manuel Adriazola P.
slightly stronger traction on the occipital component of the extraoral,
keeping the forces slightly directed above the occlusal plane and
decreasing the vertical extrusion trend of the upper posterior teeth,
while simultaneously allowing for the effective distalization of the molar.

Manuel Adriazola P.

octohedral
Types of extraoral arches, a combined extraoral arch with direction is preferred
force parallel to the occlusal plane or slightly above it.
The length of the external arch of the extraoral is important to avoid tilting.
undesirable molar. This should end adjacent to the first upper molar. Have a
straight or downward bent external arch offers greater tendency for inclination
distal in the crown of the first molar, while using a shorter external arch,
or leaning upwards from the outer arch, causes a greater tendency of the roots
to distalize before the crowns.
In cases of high angle, where little distalization of the molar is needed, it can
only be used an external occipital. In cases of very low angle, where the
musculature is strong enough to reduce the vertical extrusion of the teeth
posteriorly, only an extracervical buccal can be considered.
Manuel Adriazola P.
A secondary method of upper anchor support is the palatal bar. This
it is usually placed when the upper molars have been rotated
appropriately, and be situated in a class I relationship.
Control of the posterior segments: lower arch
When additional anchoring support is necessary in the lower posterior segment,
a lingual arch can be placed. The lingual arch remains in position during the
leveling and aligning, being useful during the initial phase of separating the incisors
with distal attachments (conjugated). The use of the lingual arch and distal attachments is
suitable for anchor support in 80-90% of all cases.
In cases with severe previous overcrowding, where additional support is needed from
Anchor, springs can be increased in the
Manuel areas P.
Adriazola of crowding of the incisors, and
Class III elastics can be applied to the lower canines, once they are already
has reached the stage of the 0.016” round wire.
The use of class III elastics should be delayed until at least the stages of
round wire 0.016" to prevent extrusion of the incisors. When the vector of
downward and mesial force on the upper molar is contraindicated, it can be
Use a palatine bar and a high traction extraoral to avoid that effect.
Control of anchoring in the vertical plane
There are two important areas of anchor control in the vertical plane:
Vertical control of the incisor. Anterior control is necessary in leveling and alignment.
of cases of deep bite, to restrict temporary increases in the
overbite.
Vertical control of the molar. It is necessary to control the molar and premolar in cases
high-angle skeletal, to avoid the extrusion of the posterior teeth and greater
opening angle of the mandibular plane.
Manuel Adriazola P.
Vertical control of the incisor
The straight arch appliance temporarily deepens the anterior bite during the
leveling and alignment, mainly due to the inclination of the brackets of the
canine.
This effect is more pronounced in the upper arch. If the canines are tilted.
distally, the mesial part of the slot of the canine bracket is directed in
occlusal direction. When the wire passes through the canine bracket, there is a tendency to
force the slots of the incisors' brackets towards incisal. If the wire is
placed on the incisors, produces extrusion of these teeth. This effect can be
avoided by not placing brackets on the incisors and not tying the wire on the
brackets of the incisors, until the rootsAdriazola
Manuel of the canines
P. have been verticized
and movements distally under control of the distal ties.
Once the roots of the canines are more parallel to the occlusal plane, the
Incisors can be interlocked without causing extrusion.

Effects of the inclination of the canine brackets. If the canines are verticalized or
tilted distally at the beginning of the treatment, can cause extrusion of the
incisors.

o
It is important to avoid tying the wire to the semi-erupted canines, so that
undesired vertical movements of the incisors and premolars do not occur, and do not
deform the wire arch during the initial phases of the treatment.

Manuel Adriazola P.

The excessive deflection of wires in unerupted canines produces

vertical movement of the lateral incisors and premolars, which should be avoided.

Undesired effects can be reduced by tightening the braces of the

dogs to the wires with elastic thread, instead of inserting and tying wire to the
slot of the canine bracket.
Manuel Adriazola P.
Vertical control of the molar
The following methods of vertical control of the molar can be considered when
it is about the cases of the highest angle:
The upper second molars are generally not banded initially or
They receive direct bonding brackets to reduce the extrusion of these teeth. If
they need bands, they must be oriented through a wire placed by the first
molar to prevent extrusion.
If the upper first molars need expansion, we can try to do the
movement in the body instead of inclination, to avoid the extrusion of the cusps
palatinas. This is best achieved with a fixed expander, disjunction, sometimes combined.
with a high traction extraoral. Manuel Adriazola P.
If the palatine bars are used, they must be placed approximately 3mm apart.
removed from the palate so that the tongue can exert a vertical intruding effect on
these teeth.
When using extraoral devices in cases of high angles, an extraoral device is used.
high traction. The extraoral cervical traction is avoided.
In some cases, a bite plate on the upper or lower region of the molar is
useful for decreasing the extrusion of the molars.
Access to the anchor in the lateral (coronary) plane
In most cases, it is not necessary to maintain control of the lateral anchor,
but the following points are important in certain treatments.
Inter-canine distance. The upper and lower inter-canine distance must be maintained.
as close as possible to the initial dimensions for stability, it must
take care to ensure that the
Manuel Adriazola P.
crowding is not relieved by the uncontrolled expansion of the lower arches and
superiors.
Cross bites of the molar. Care should also be taken to avoid correction of
the crossed bites from the tilt movements.
This allows for the extrusion of the palatal cusps and an unwanted opening of the plane.
inferior in the treatment of the high angle, and even problems with routine cases of
Class II-1. As much as possible, the crossbites of the molar should be
corrected with full body movement.

Manuel Adriazola P.

The palatine bars can be made approximately 3mm away from the
palate, so that the forces of the tongue can assist in vertical control.
Expansion of the superior intermolecular distance due to inclination, resulting in
extrusion of the palatal cusps represents the lack of vertical control of the molar. It is
preferably full body movement.
Manuel Adriazola P.
Surgical treatment of the maxillary bone can be performed when it is very
narrow, it should be considered a rapid early expansion, as a procedure
independent before leveling and aligned.
The minimal crossbites of the molar can generally be corrected in the
final stage of leveling and alignment using rectangular wires that are
slightly more expanded.

Manuel Adriazola P.

The use of a more expanded rectangular wire to correct a crossbite

minimum of the molar, during the final stages of leveling and aligning. The control of
Torque is useful for achieving movement in a body, rather than just a simple tilt.
Various aspects of leveling and aligning Wire sequence
The initial wire arches should apply light and gentle forces. The sequence of
The wire arch is as follows: round 0.015” twistflex, 0.0175” twistflex, 0.014”,
0.016”, 0.018”, 0.020” and then rectangular steel wire 0.019 x 0.025”.
The sequence varies in relation to the complexity of the malocclusion. In more complex cases,
It can be difficult to maintain a specific size for more than a month, and in some cases
easier, it is possible to avoid some wire sizes. Nickel wires
titanium (0.012, 0.014") can be used during the stage

o
of leveling and alignment. However, its two main disadvantages are its cost and
its flexibility.
The excessive deflection of these wires causes distortion of the shape of the arch and
movements in the occlusal plane.
Exceptions for the total placement of braces.
The placement of braces on all teeth is recommended at the beginning of most
of the treatments. This allows for early stabilization of the shape of the arch and
it also helps in controlling the canines during their initial retraction. The
Exceptions for the total placement of brackets are the following.
Cases of deep bite in high angle, where the upper incisors
they interfere with the placement of brackets
Manuel onP.the incisors
Adriazola
inferiors.
These cases are not common, but when they occur, the upper incisors can
to receive braces and the lower incisors do not receive them at the beginning of the treatment.
After leveling and aligning in the upper arch for 2 to 3 months, and the
upper incisors have been slightly labioverted, the lower incisors
They can then receive braces. This avoids unnecessary extrusion of the teeth.
later during the alignment and leveling procedures. In cases of bite
deep bite angle, it can be considered a bite plate, and the brackets of
The lower incisors can be placed during the initial visit, if the occlusion allows it.
I allow you.
Cases with unerupted teeth, or teeth out of shape.
arch.
These teeth can remain without braces until adequate space is obtained for
its movements. Once the space is created, these teeth can receive
brackets, slightly tying them with an elastic wire to the main arch
When the canines are vertical or tilted distally.
Manuel Adriazola P.
The tilt in the brackets of the canines creates an inclined position of the slot.
toward the incisal. When the wire passes through those slots, it tends to be bent
toward the incisal. If this wire is tied to the brackets of the incisors, the wire
it has a tendency to extrude these teeth, this effect is greater in the upper arch
due to the greater amount of inclination in the brackets of the upper canines.
It is better not to place braces on the incisors until the roots of the canines
have been distalized, leaving the slots of the canines more parallel to the plane
occlusal.

Manuel Adriazola P.

Correct technique for aligning a crowded incisor, first, a

sufficient space, and a gentle tilting force is applied, the tooth will move almost by
completes to the line of occlusion. If heavy force is applied, the crown of the tooth will
it will tilt towards the vestibular and the root towards the palatine.
Procedures for re-leveling
It is necessary to repeat the alignment and leveling procedures in most of the
cases, when pre-set devices are used. Rese leveling is necessary both
in newly erupted teeth, or incorrect positioning of brackets. During the
treatment, the re-leveling has to be done as many times as necessary
for its efficiency, but even the most experienced orthodontists fail to
try to position the brackets accurately on the first attempt.

o
During the initial leveling and alignment, these errors can be identified, and it is
better to reposition the brackets than to make bends in the wires throughout the
treatment. Two "techniques" are often used in relation to the wrong braces
positioned:
Introduction of bends in the wires at the 0.014" round wire stage.
to compensate for the error. This wire shows enough flexibility to produce
minor movements in the dental position, allowing the brackets to be
repositioned in the next appointment. Frequently the round wires 0.016
they can be placed, without delay in the treatment time. If the repositioning
the brackets are delayed until the finishing and completion stage of the treatment,
so it is necessary to return to the very lightweight
Manuel Adriazola P.wires. This increases the time of
treatment.
The repositioning of braces can also be on newly erupted teeth.
the poorly positioned; because it is necessary to return to lighter wires to
tie these teeth. Also, if the second molars were not banded up to
the stage of closing space, or reduction of horizontal transfer, the brackets can
to be repositioned in the banding appointment of the second molar and it can occur the
procedure and re-leveling without wasting time on the treatment.
Key points during leveling and alignment
The needs for lateral, vertical, and sagittal anchoring should be identified for
each case.
The distal ties should be used to control the crowns of the canines.
where necessary.
The distal folds should be used to avoid the tilting of the incisors.
when necessary.
The posterior segments must be supported with extraoral and/or palatine bars or
lingual arches, in cases of maximum anchorage.
Manuel Adriazola P.
The forces must be light (150g or less).
The 0.014" (or smaller) wires must be used until all the brackets
be properly positioned, before removing them to install wire arches
of larger caliber.
The leveling and alignment is not complete until the rectangular steel wire
stainless 0.019 x 0.025” passively fits into the groove of the brackets.

Manuel Adriazola P.
o