University of Glasgow

Transpalatal, Nance, Lingual Arch & Quadrihelix Appliances

Personal notes

2013

Mohammed Almuzian

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Table of ContentsIntroduction...........................................................................................................................................2

TPA...................................................................................................................................................2

Nance appliance.................................................................................................................................2

Lingual arch.......................................................................................................................................2

The quadhelix....................................................................................................................................3

Indication of Transpalatal, Nance, Lingual Arch...................................................................................3

A. Passive Use................................................................................................................................3

B. Active uses................................................................................................................................7

Complications........................................................................................................................................8

Quadhelix appliances.............................................................................................................................9

Types.....................................................................................................................................................9

Design.................................................................................................................................................10

Indications...........................................................................................................................................10

Advantages......................................................................................................................................11

Disadvantages......................................................................................................................................11

Clinical Management...........................................................................................................................11

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Transpalatal, Nance, Lingual Arch & Quadrihelix Appliances

Introduction

TPA

It was originally described by Robert Goshgarian in 1972,

It is constructed from a thick wire that goes across the roof of the mouth from

one molar or premolar to contralateral molar or premolar

It is made from 0.9 or 1.25 mm stainless steel. Some recommend the use of

TMA in the construction of removable TPA in order to derotate the molars

efficiently. (Mandurino & Balducci, 2001)

It is either soldered or feeded in the lingual attachments (lingual sheath, Wilson,

or Mershon attachments of the molar bands) (Kuftinec, 2004; Moutaftchiev &

Moutaftchiev, 2009). Other modification is to bond the palatal arch directly to

the lingual surface of the molars (Kuftinec, 2004).

Nance appliance

It was firstly described by Nance in 1947,

It is made from 0.9 or 1.25 mm stainless steel with the acrylic portion (heat,

cold or even light cured acrylic or composite) of the Nance palatal arch should

be as large as possible, e.g. minimum size of a 10 pence piece, 

It should be positioned in the highest part of the vault of the palate so that it

rests on non‐compressible mucosa.

Lingual arch

It could be constructed from 0.9 or 1.25 mm SS

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It is either soldered to the molar bands, feeded into the molar sheath

(Removable lingual arch) or even bonded directly to the lingual surface of lower

molars.

The effect of using thinner or thicker wire in constructing the lingual arch

A study by Owais in 2011 showed that with 1.25 mm SS lingual arch, the forces

on the lower incisors and first molars increased because of the increased

stiffness in comparison to 0.9 mm SS

This might resulting in more proclination of LLS and lower second primary

molar extraction space loss but the angulation of the primary molar stay stable.

Another finding was that the failure rate due to cementation failure or wire

breakage was more with 1.25 mm SS lingual arch which could be explained

again as a reason of increased wire stiffness.

The quadhelix

It is a useful intermediate upper arch expansion device and has been extensively

described and popularised by Ricketts (1979).

Indication of Transpalatal, Nance, Lingual Arch

TPAs uses will be explained in more details because of the popularity of their

uses. Nance and lingual arches will be explained later. However the uses of the

TPA can be sub classified into two categories:

A. Passive Use

1. Interceptive treatment

I. Interceptive treatment of palatally displaced canines. An RCT by

Bacceti 2011involving 120 subjects based on palatally displaced

canines diagnosed on panoramic radiographs and they were randomly

assigned to one of four study groups (RME followed by TPA therapy

plus extraction of deciduous canines, TPA therapy plus extraction of

deciduous canines, extraction of deciduous canines, EC group). The

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success of canine eruption was 80%, 79%, 62.5% and 28% respectively.

The use of a TPA in absence of RME can be equally effective than the

RME/TPA combination in PDC cases not requiring maxillary

expansion, thus reducing the burden of treatment for the patient.

II. Digit and tongue thrust habit breaker if a crib is soldered to TPA (Clark,

1983)

III. Space maintainer after premature loss of primary molars to prevent

crowding of the premolars or when the E space is required to relieve

minimal crowding in the anterior teeth. There are many studies looking

at the effectiveness of the lingual arch in maintaining the Leeway space.

Brennan & Gianelly 2000 found that a lingual arch placed during the

mixed dentition, the arch length decreased by 0.44 mm and there was a

gain of 4.44 mm leeway space. However it was shown that intercanine

is increased after using lingual arch due to the canines migrating

distally. Other studies by Villalobos et al.(2000), DeBaets and Chiarini

(1995) and Rebellato et al. (1997) also showed that lingual arch reduced

the loss of leeway space but increase the possibility of lower incisor

proclination.

2. Transverse anchorage and Arch width stabilization

I. To improve arch width stability when aligning palatally impacted

maxillary canine (Fleming &Sharma, 2010).

II. CLP case after expansion of the maxillary arch to restore the arch form

between the major and lesser segments and just before alveolar bone

grafting (Harris & Hunt, 2008).

III. As a retainer after RME or after surgical expansion or constriction of

the palate in order to hold the osteotomies part together during healing

period (Harris & Hunt 2008).

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IV. It is used to counteract the buccal tipping of the crown of the molars

during intrusion of the anterior teeth using Segmented Burstone Arch

Wires mechanics (Burstone, 1966).

V. For the same reason its use is recommended with Class II bite correctors

to counteract the buccal forces applied by the (TFBC) Twin Force Bite

Corrector (Rothenberg, 2004).

VI. Adjunct with HG to reduce buccal tipping of the molar and palatal cusp

hanging the molar distalization (Baldini and Luder, 1982). However, a

study by Wise et al. (1994) showed no difference with or without use of

a TPA during molar distalization by HG.

VII. TPA are used with palatally or buccally placed TAD to control molar

tipping when posterior teeth are intruded to treat anterior open bites

(Cousley 2010).

3. Vertical Anchorage: Placing the TPA 4mm away from the palate might

introduce some intrusive effect by the tongue on the molars which can help in

correcting or controlling the over eruption of maxillary molars (Goshgarion,

1972).

4. AP anchorage

The Nance appliance can be used to provide anchorage to distalize the molars

such as the Pendulum Appliance (Hilgers 1992); Wilson rapid molar

distalization (REF); the distal jet (Carano 1996): Jones Jig (REF) and the Lokar

Distalising Appliance (Jones and White 1992).

TPA can be used to maintain molar position after distalization. (Prakash 2011).

TPA can be used at start of treatment when moderate anchorage requirement is

needed since it would theoretically bring the roots of the upper molars in

contact with cortical bone if they were forced to move mesially and would

supplement their anchorage values (Cortical anchorage) (Radkowski 2007,

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Root, 1986). There are many studies that compare the effectiveness of the TPA

with other methods of anchorage reinforcements:

I. Zablocki & McNamara 2008, the mean anchor loss of 4.1 mm was seen in

association with the TPA and 4.5 mm in control group.

II. Feldmann, 2009, RCT to measure the anchorage loss with Onplant (1), TAD

(2), EOT (3) & TPA (4). They found that after levelling/aligning phase: the

anchorage was stable in the group 1,2 & 3 while group 4 showed 1.0 mm.

while after space closure phase, the anchorage was stable in the group 1 & 2 but

group 3 & 4 showed 1.6 and 1.0 mm of mesial drift of molars respectively.

III. Stivaros 2010 compare Nance and TPA appliances and found that both

appliances are effective in preserving anchorage with an average OA loss of

around 1mm over 6 months and there is no difference in anchorage support

between them but TPA well tolerated by the patient.

IV. Feldmann, 2012, measured the patients’ perceptions in term of pain, discomfort,

and jaw dysfunction with Onplant (1), TAD (2), EOT (3) & TPA (4). The

results confirm that there were very few significant differences between

patients’ perceptions of skeletal and conventional anchorage systems during

orthodontic treatment

V. Sharma et al. 2012 compared the use of TPA with TAD regarding the

orthodontic anchorage and found 2.5 mm of mesial movement of the U6s with

TPA while Mini-screw implants provided absolute anchorage during U3s

retraction

VI. TADs or TPA? Liu 2009 compared the use of TPA and TADs in he found that

better dental, skeletal and soft tissue changes could be achieved

by minicrew implants especially in hyperdivergent patients. Skeletal anchorage

should be routinely recommended in patients with bialveolar dental protrusion.

VII. Interesting, in a finite element study, Kojima et al. (2008) show that TPA

provides no antero-posterior anchorage.

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5. Molars antirotation effect: Another advantage of TPA is the provision of

antirotation effect on the molars during incisor retraction (Goshgarian, 1972).

6. Method of attachment for auxiliaries.

More recent novel ways of using TPAs is the incorporation of finger or ballista

springs to aid eruption of impacted maxillary canine (Shaushua & Becker 2012)

FIGURE: PHOTO NEEDED.

Lingual arches can be used to provide attachment to extrude multiple teeth after

their failure of eruption like Jerusalem approach (Becker, 1997), the Belfast–

Hamburg (Behlfelt, 1987), the Bronx approach (Berg, 2011) and the Toronto–

Melbourne (Smylski 1974; Hall, 1978) in the management of multiple failures

of eruption associated with Cleidocranial Dysplasia. In general, all these

approach include timing extraction of primary and supernumerary teeth,

surgical exposure of the permanent teeth followed by applying attachment to

start teeth alignment

Modified Nance appliance with anteriorly positioned acrylic bottom can be used

to treat anterior deep by acting as a fixed acrylic frontal bite plane. Prakash,

2011

B. Active uses

1. Posterior teeth intrusion through the effect of the reciprocal force of the tongue

when the TPA is constructed 5mm clear of the palate. Wise et al. (1994) in a

retrospective study found that TPA compared with the control, might be used to

control the maxillary vertical growth.

2. Upper arch expansion and constriction: in a similar way to quadhelix where the

TPA can be expanded by 3-4mm to provide a force of 200gm that can help in

expansion of the maxillary arc. It can be constricted by the same amount to aid

in arch constriction Ingervall et al. (1995)

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3. Distalization of the molars unilaterally or bilaterally can be used to correct mild

class II (Rebellto 1995, Ten Hoeve, 1985; Mandurino and Balducci, 2001) by

complicated ways of activating the V shape bend of the TPA as described by

Rebellto in 1995. In unilateral case it is better to reinforce the stable side with

headgear, place torque in the archwire to take advantage of cortical anchorage

or use temporary anchorage devices (Haas, 2000, Burston 1980, Rebellto,

1995, Cooke and Wreakes, 1978; Ten Hoeve, 1985; Dahlquist et al., 1996;

Ingervall et al., 1996)

4. Rotating the molars

Correction of rotation which allows the easy insertion of the

HG inner bow. It thought that this movement might provide

extra arch length. The removable TPA can easily do this by

activating the V shape bend. (Rebellto 1995)

Rotating the molars for better finishing: Rotating the molar mesiobuccally

especially in class II treatment where there has been two upper premolar

extraction. The TPA may help to achieve super class molar relationship due to

extra space of removing two units in the upper. (Rebellto 1995)

5. Mesial or distal tip movement in order to achieve Andrew molar features or to

correct distal tipping after HG uses or to upright the molars after space closure

(Rebellto 1995)

Complications 1. TPA

A. Impingement of the palate as the molars moves mesially. To avoid this,the V

shape bend or loop should be directed distally. However, the TPA implication

on oral hygiene (OH) is less than Nance appliance (Stivaros 2010). Feldmann in

2012 showed that there were very few significant differences between patients’

perceptions of skeletal systems (Onplant/TAD) and conventional anchorage

systems (HG/TPA) during orthodontic treatment

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B. Some claims that TPA use will put the roots of the anchor units against the

cortical bone plate which is associated with high risk of root resorption

(Topkara, 2012, )

C. Breakage and cementation failure

2. Nance appliance:

A. Breakage and cementation failure

B. The complications of the Nance appliance are one of OH and inflammation of

the palate. A common problem is the acrylic ‘button’ becoming embedded and

possibly covered over by the palatal tissues especially during space closure in

patients with poor OH. (Singh 2009). The main limitation of the Nance

appliance is the frequent need for its removal during space closing mechanics.

To overcome this potential problem, the use of Nance+TPA ‘combo’2 was

introduced (Yuan 2012). This combination appliance acts under this philosophy:

With Nance+TPA ‘combo’2, the Nance button portion of the arch can be

removed in treatment during space closure, whilst leaving the transpalatal arch

portion in situ to provide some be it limited A–P anchorage.. (Yuan, 2012).

3. Lingual arch:

4. As previously discussed 2 main side effects of using lingual arch is the increase

in intercanine width as the 3s migrate distally and the proclination of lower

incisors as a result of the reciprocal force on the lingual surface of lower

incisors.

A. Breakage and cementation failure

Quadhelix appliances

Types

A. Custom made: 1-0·9mm stainless steel with four helices to increase flexibility

B. Preformed ready type

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A removable or fixed quadhelix constructed of Blue Elgiloy for increased

flexibility/ adjustability and an Elgiloy based system called ORTHORAMA

Removable nickel titanium versions have also been introduced which may offer

more favourable force delivery characteristics. But study showed that the factor

effect the efficiency of the system is the size of the appliance and diameter of

the wire not the material. Ingervall,1995

Design

The quadhelix is a fixed appliance retained by bands

cemented on the permanent first molars.

It consists of a w-shaped 1mm spring, usually

stainless steel, incorporating 4 helices to add

flexibility and increase range of action.

The quad helix consists of a pair of anterior helices and a pair of posterior

helices.

The portion of wire between the two anterior helices is called the anterior

bridge.

The wire between the anterior and posterior helices is called the palatal bridge.

The free wire ends adjacent to the posterior helices are called outer arms.

Indications

1. Intermediate upper arch expansion

2. Bi-helix used in mandibular arch in grossly narrowed or distorted arches, or to

aid correction of severe scissors bite

3. Expand the upper arch anteroposteriorly when its arm

length increased

4. Provide access and space with cleft palate before bone

grafting

5. Used with facemask same as RME

6. Molar derotation

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7. Habit breaking effects

8. Method of attachment to align impacted teeth or to perform certain teeth

movement

9. Provide some AP and transverse anchorage

Advantages

1. Reduced need for patient compliance because it is fixed

2. Efficient :

The quadhelix produces a combination of buccal tipping and skeletal expansion,

typically in the ratio.of 6:1. (Frank 1982)

Quad. (QH and RME success rates is 100%, Harrison and Asly 2008 Cochrane

review)

Quadhelix versus buccal arch expansion — no difference in expansion achieved

and buccal arch cheaper McNally 2003

Herold (1989) compares the use of RME, a quadhelix and a removal appliance,

and came to the conclusion that no method of expansion was substantially better

than the other.

Disadvantages

1. The limited amount of skeletal change,

2. Opening of the bite due to molar buccal tipping.

Clinical Management

The desirable force level of 400 g can be delivered by activating the

appliance by approximately 8 mm, which equates to approximately one molar

width.

Patients should be reviewed on a six-weekly basis.

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Sometimes, the appliance can leave an imprint on the tongue; however, this

will rapidly disappear following treatment.

Expansion should be continued until the palatal cusps of the upper molars

meet edge-to-edge with the buccal cusps of the mandibular molars.

Retention after the expansion

A. At least three-month retention period before it is removed

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

C. If fixed appliances are being used, the quadhelix can be removed once stainless

steel wires are in place.

D. Replaced by TPA.

4. Delivery and Activation of TPA

4.1a Initial Activation

The first step in delivering the appliance is to place it passively in the mouth. After the proper fit of the bands and the TPA has been verified, the TPA should be removed from the mouth and evaluated. Normally, mesial rotation of the upper molars will be evident, as indicated by the orientation of the molar tubes relative to the mid-sagittal plane (Fig. 10A). In addition, the need for buccal root torque also is evident (Fig 10B).

The initial activation of the TPA is made simply by grasping the solder joint with the ends of a Weingart plier. The anteroposterior activation is accomplished using finger pressure (Fig 10C), while buccal root torque can be applied by bending the TPA occlusally (Fig 10D). At the end of the activation, the right buccal tooth should be parallel to the midsagittal plane (Fig 10E) , and the occlusal surface of the right molar band should be perpendicular to the midsagittal plane ( Fig 10 F ).

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Figure 9: Initial activation of the TPA. By convention, the right side of the appliance is activated first.

4.1b Subsequent Activation

About 6-8 weeks is required for the molar rotation to occur on the activated side.

The TPA is fully activated and needs no further adjustment when the buccal tubes approximate the midsagittal plane (Fig 11A) and when the occlusal surfaces of the bands are perpendicular to the midsagittal plane and parallel to each other (Fig 11B). The TPA can be left in place for the duration of fixed appliance treatment as both an intra-arch stabilization appliance and as an appliance serving as anchorage for other orthodontic movements.

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Figure 10: Evaluation of TPA activation. A) Before activation. Note the convergent orientation of the tubes on the upper first molars. B) After final activation. Clinically, the facebow tubes on the molar bands should be parallel to each other.

Fabrication Figures from Ferdianakis 1998

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Other Uses of the FLA - Welded and Soldered Finger Springs

For esthetics-conscious patients, especially adults, the lingual arch can sometimes be used alone. In more demanding cases, however, lingual finger springs are more esthetic and often more effective than buccal archwires.

Active springs can be welded or soldered to the lingual arch, which becomes a passive anchorage unit. A stainless steel arch requires soldering, but high-springback wires can be welded to TMA.

In cases where bicuspids are blocked lingually or require expansion, an .018" round finger spring welded to the .032" × .032" lingual arch will move the teeth buccally Fig 9a

A lingual finger spring to a lingual button can move an erupting second molar lingually (Fig. 9b).

This is particularly helpful with mesially rotated molars, because buccal wires tend to

displace these teeth buccally.

9a 9b

To gain space in the arch, an 0.018" round finger spring is welded to an .032" × .032" lingual arch. When the finger springs are activated, they produce a labial and intrusive force (Fig. 9c). The effect is to flare the anterior teeth and tip back the molars.

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An unbanded second molar sometimes erupts occlusal to the first molar in a case where the curve of Spee has been leveled and the first molar has tipped back. An 0.018" finger spring, welded to the lingual arch and fitted to the occlusolingual groove of the second molar, will lift the first molar occlusally on the distal side, steepen the plane of occlusion somewhat, and intrude the second molar (Fig. 9d). Once the second molar is in line, the spring can be left in place to hold the occlusal relationship. A similar spring can be used to move a second molar buccally.

Fig 9d

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