A Multi-Disciplinary Approach to Class III TherapyUsing The Delta Force and ALF Appl iances in Conjunction with Terminal Arch Extract ionsBy J. Wellington (Skip) Truitt, DDS & Livier Carreon-Truitt, DDS

Spring 2008 Reprinted from the Journal of the American Orthodontic Society www.orthodontics.com Spring 2008

The panoramic radiograph showedthe third molars to be developing verywell in all four quadrants. (Fig. 9)

The following was the proposedtreatment plan:

• Develop the maxilla using a combina-tion of ALF and Delta Force appliances.

• Remove the mandibular second molarswith the view to third molar replacement.

• Level and align the mandibular arch withno torque using the Delta Force appliance.

• Distalize the lower buccal segmentsand retract the mandibular incisors.

• Burn anchorage within the maxillaryarch using a Forward Pull (Reverse PullHead Gear).

• Remove the maxillary second molarswith the view to third molar replacement.

• Retain the finish case with upper andlower Spring Hawley retainer.

Treatment began by placing anupper ALF appliance on First MolarBands with standard pre-adjusted.022 buccal tubes containing 10° oftorque. (Fig. 10)

Composite ledges were placed onboth the left and right maxillary 1stbicuspids to secure the crescent wiresof the ALF appliance. (Fig. 11) Allthree of the anterior omega loopswere activated. The omega loopsmesial to the first molars were leftpassive to function as shockabsorbers. (Fig. 12) 4, 5, 6

Delta Force brackets were placedon the maxillary teeth through thesecond bicuspids. The starting upperarch wire was .020 x .020 beveledmulti-gradient thermal Niti. All of theDelta Force brackets were placed inthe minimum ligation configuration.(Fig. 13, 14 & 15) The ligature elasticswere replaced every four weeks, and

the .020 x .020 arch wire wasreplaced every sixty days with a newarch wire of the same type and gauge.

The treatment objective for thisfirst phase of therapy was to developthe maxillary arch over the mandibulararch. Once this first phase of treat-ment was accomplished therapy couldbe initiated on the lower arch.

The mandibular second molarswere removed and the lower arch wasplaced in the Delta Force appliance.The arch wire gauge was .018 multi-gradient thermal Niti. The objectivewas to level and align the dental alveo-lar base with no torque maintainingthe skeletal Class III compensation.(Fig. 16 & 17) 7,8,9,10,11,12

Once the lower arch was leveledand aligned .045 molar distalizingsprings and .022 arch wire lockswere placed mesial to the firstmolars (Fig. 18) The springs were

The use of the low frictionDelta Force appliance inconjunction with the bio-compatible forces generated

by the ALF appliance creates a newapproach to treating under-developedarches. It is now possible to developthe size of both the upper or lowerarch and level, align and torque theteeth all at the same time.

The patient used as an examplefor this article was a Hispanic male13.4 years of age. His chiefcomplaint was his unaesthetic smile.Complete orthodontic records weremade at his initial appointment.(Fig. 1-7)

Evaluation of the Bimler EliteCephalometric analysis showed thepatient to be a skeletal Class III anda skeletal Division II in both the sizeof the maxilla and the position ofthe maxilla. (Fig. 8) 1, 2, 3

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Spring 2008 Reprinted from the Journal of the American Orthodontic Society www.orthodontics.com Spring 2008

activated unilaterally and both firstmolars were distal driven. The firstmolars were then locked in positionwith new arch wire locks.

The distalizing springs and archwire locks were then placed mesial tothe first bicuspids. Both the first andsecond bicuspids were bilaterallydriven to contact the first molars. Theligation of the bicuspids was in theminimum configuration reducing thefriction. (Fig. 19, 20 & 21)

The mandibular cuspids were nextretracted using 3/16”, 41/2 oz. elas-tics from the cuspids to the firstmolars. Note the arch wire lockmesial to the lower first molar andthe Delta Force rotating wedge on thedistal of the upper cuspid. (Fig. 22)

After bilateral cuspid retractionwas fully completed steel ligaturewire was tied from the first molasthrough the cuspids and the arch wirelocks removed mesial to the firstmolars. A six unit chain elastic wasplaced cuspid to cuspid to retract thelower incisors and correct the dentalmidline. (Fig. 23, 24 & 25)

Once the upper arch developmentwas completed the ALF appliancewas removed. The upper .020 x .020multi-quadrant thermal Niti arch wire

was replaced with a .018 x .025steel arch wire. Elastics were wornfrom the upper first molars to theReverse Pull Head Gear. These elas-tics were 5/16”, 8 oz., and wereworn at night only. The objective wasto “burn anchorage” in the upperarch. (Fig. 26 & 27)

The final step in the treatmentwas to insure the patient hadcorrect cuspid and anterior guid-ance. This was accomplished bywearing 1/8”, 41/2 oz elastics fromthe upper cuspid pendulum to thelower cuspid and first bicuspidpendulums in a triangle configura-tion. These elastics were worn fulltime except for eating and hygieneand changed by the patient everytwelve hours. (Fig. 28)

The maxillary second molars werethen extracted. The upper arch wirewas removed and ligature elasticsplaced around all of the empty brack-ets in the medium configuration forprotection. The lower arch wire wasleft in place to act as a retainer. Theocclusion was allowed to function forfour weeks and re-evaluated.

Both the occlusion and the func-tion of the Temporal MandibularJoints were normal at the end of

this four week period. The DeltaForce appliance was totally removedand the patient placed in upper andlower Spring Hawley retainers. (Fig.29 & 30)

The retention period was sixmonths active retention (full-timewearing except for eating andhygiene), followed by six monthspassive retention (night time wear-ing only) sequencing out of theretainers one night per month. Atthe end of the twelve months thepatient wore the retainers only oncea week at night.

The patient was then monitoredon a six month basis until all fourthird molars had erupted into occlu-sion. (Fig. 31)

Active treatment time from theinitial placement of the upper ALF andDelta Force appliances to the begin-ning of retention was fourteen months.

The post retention records demon-strate the long term stability that wasobtained by compensating the skele-tal Class III. (Fig. 32 & 38)

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Spring 2008 Reprinted from the Journal of the American Orthodontic Society

References:1 Truitt, J.W. Cephalometrics for Today.

FJO 1989, Vol.6(3): 5-11 & 47

2 Bastein, G.B., Truitt, J.W. The BimlerCephalometric Analysis. 1985 OrthoOrganizers, Inc., San Marcos, California

3 Truitt, J.W. Advanced Orthopedic andOrthodontic Therapy. 1987. ClinicalFoundation of Orthopedics & Orthodon-tics. Gainesville, Texas.

4 James, G.A., Stroken, D., “The Signifi-cance of Cranial Factors in Diagnosisand Treatment with the AdvancedLightwire Appliance.” Int. Journal ofOrthodontics, 14: 3, pgs. 17-23, 2003.

5 Smith, G.H., Ashton, A., ALF ReducesOrthodontic Relapse Factor. The Func-tional Orthodontist, pages 16-20, Nov./Dec. 1996.

6 Nordstrom, D., Positive Alveolar andGingival Effects of the ALF Appliance.The Functional Orthodontist, pages 4-6,Nov. /Dec. 1996.

7 Wilson, H.E., The extraction of secondmolars as a therapeutic measure. Trans.Euro-Ortho Soc. 1966: 141-145.

8 Wilson, H.E., Long term observation onthe extraction of second permanentmolars. Trans Euro-Ortho Soc. 1974:215-221.

9 Liddle., D.W., Second molar extractionin orthodontic treatment. Am JournalOrthod 1977: 72(6): 597-616.

10 Orton-Gibbs, S., Crow, V., & Orton,H.S., Eruption of third molars after theextraction of second permanent molars.Part 1: Assessment of third molar posi-tion and size. Am Journal Orthod 2001;119(3): 226-238.

11 Witzig, J.T. & Spahl, T.J., The ClinicalManagement of Basic Maxilla FacialOrthopedic Appliances. Volume II. 1989PSG Publishing Co., Inc., Littleton,Massachusetts.

12 Witzig, J.T. & Spahl, T.J. The ClinicalManagement of Basic MaxillofacialOrthopedic Appliances. Volume II. 1989PSG Publishing Co., Inc., Littleton,Massachusetts.

Dr. Livier Carreon-TruittDr. Carreon-Truitt graduated from the Universidad de Guadalajara, Mexico in 1985. Her practice hasbeen limited exclusively to orthodontics since 2002 in Guadalajara, Mexico. She is currently in hersecond semester of a Specialist Orthodontics Masters Degree program at the Universidad deGuadalajara, Mexico.

Conclusion:The technique that has just been

presented using a low friction DeltaForce appliance in conjunction withan ALF appliance reduces the timeof treatment, but also greatlyincreases the stability of the case.The key mechanical principles to

understand are the ability toreduce friction within the bracket,and being able to begin torquingthe teeth at the very start of thetherapy. This in turn creates aparallel relationship of the rootsand reduces the forces required forsliding mechanics.

Dr. J. Wellington ( Skip ) TruittDr. Truitt received a Bachelor of Science degree from Texas Christian University and his Doctorate ofDental 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 inAustralia, Thailand, Singapore, South Africa, Mexico, Ireland, Norway, Germany, the United Kingdom,Canada and the United States. He is affiliated with the American & Texas Dental Associations, theAmerican Association for Functional Orthodontics, the International Association for Orthodontics andthe Australian Association of Functional Orthodontics. Co-author of four text books and published innumerous papers world wide on the subjects of Maxillofacial Orthopedics, Orthodontics and TMD Therapy, Dr. Truittconducts a series of international seminars on these topics through the Clinical Foundation of Orthopedics & Orthodontics(www.cfoo.com), which are available on a DVD series. Dr. Truitt may be contacted at skipcfoo@suddenlink.net

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