The Galler Spacing Technique (GST) Manual
By: David Galler DMD EDITED by: Caroline Quiong DDS MS 1
Table of Contents: 1.
INTRODUCTION TO CLEAR ALIGNER THERAPY
2.
HISTORY OF IPR
3.
THEORY
4.
COMPLICATIONS
5.
CURRENT TOOLS AND
TECHNIQUES 6.
GOALS
7.
TOPICAL ANESTHETIC
8.
GALLER SPACING TECHNIQUE
9.
STEP BY STEP PROCESS
10. DISCUSSION 2
Introduction to Clear Aligner Therapy With the advent of new technology and techniques to achieve minor orthodontic movement in the 21st Century, more adults are choosing to improve their smiles with orthodontics. Statistics indicate that approximately 70% of the adult population has some amount of spacing, crowding, or malocclusion (Dentalproducts.com Jan 2010). Previously, only a limited group of adults would be willing to endure the wires and brackets of fixed orthodontics (1 in 2500 adults- goftp.com) — because although extremely effective, cosmetics had to be compromised. With the revolutionary breakthroughs of the orthodontic o rthodontic “aligner”— clear, removable, hard plastic designed to precisely fit
over teeth to move teeth — nearly clear orthodontic movement is now possible. With this new approach, the orthodontist and the general dentist now have the ability to achieve minor orthodontic movement without severely compromising cosmetics. Today, these new devices and technology can be implemented to improve the Standard of Care regarding the treatment of adult dentition. 3
In the past, correcting spacing problems in cosmetic dentistry primarily involved bonding or the placement of porcelain veneers to improve the appearance of a patient’s teeth. Minor orthodontic movement with fixed brackets and wires in the anterior region is also another approach that can be utilized to correct such spacing problems. Now, with the introduction of clear, orthodontic aligners, the implementation of the orthodontics itself can also be considered previously unaesthetic smiles can be in a way “cosmetic”. Many previously ‘made-over’ using just clear aligner technology and represents a
far less invasive approach to treating t reating spacing problems than with prosthodontics. In addition, minor orthodontic movement can also be used to enhance and simplify future cosmetic and restorative treatment plans. There are even even times when it is imperative that a dentist use some form of minor orthodontics to enable a restorative treatment plan to succeed. ( NYSDJ, Jan 2009) Knowing how to implement minor orthodontic movement is quickly becoming a necessary component in the methodology of dental schools are placing added today’s quality d entist. Even dental focus on its usage. Currently, 36 of the 58 dental schools in the United States offer their students education on some form f orm of clear aligner orthodontic movement. It’s those dentists who are
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comfortable, confident and above all capable of utilizing such technology who will be among the future leaders of dentistry.
5
HISTORY OF IPR In most cases of crowding, an essential step required to achieve minor orthodontic movement is a procedure called InterProximal Reduction or IPR. Dr. Jack Sheridan, DDS, MSD, is credited as the inventor inv entor of a way of removing enamel to resolve moderate crowding, while eliminating the problem of excess space associated with extractions or the vexation of coordinating expanded arches. Dr. Jack Sheridan was the first to implement IPR in a process he called (ARS). “Air Rotor Stripping” or (ARS). Dr. Sheridan used this technique to create space in combination with fixed appliance therapy to treat cases of crowding. Simply put, Dr Sh eridan advocating “stripping” the enamel from premolars in order to create space in the dental arch using air driven dental handpieces. After much debate and research, this procedure has been adapted to meet many of today’s orthodontic needs and is now commonly referred to as simply IPR. Most clear aligner adult orthodontic cases of crowding rely heavily on IPR to create needed space for tooth movement. This manual WILL NOT discuss the issues related to ‘stripping’ teeth and the short and long term effects of removing enamel. 6
We will only reference the reader to studies that have conclusively proved the system is 100% safe and effective. (ADD STUDIES FROM RAINTREE SLIDES) The problem with IPR is that it is very technique sensitive and if done incorrectly can lead to a number of iatrogenic problems. Improperly performed IPR is considered to be the second most common cause of failure in clear aligner minor orthodontic movement case with the most common cause of failure being compliance. Another problem is that most dentists though familiar with the concepts of IPR have very little training on how to perform it correctly and reliably. The IPR visit can also be anxiety-inducing for the patient patient as well. To be accepted accepted and successful, minor orthodontic movement should be as non-invasive and pain-free as possible. The premise behind IPR is fairly straightforward— to create needed space to relieve crowding — however the techniques and tools needed needed to perform IPR can also be tricky. tricky. With the advent of new tools for IPR and novel protocols in their implementation like the Galler Spacing Technique (GST), IPR can now be an easy, exact, pain-free, and stress-free procedure for the doctor and patients alike. This manual will describe the theory, protocols and tools used in the Galler Spacing Technique (GST). Disadvantages of the the current
7
systems will be explored and patient management tips will be highlighted. Upon completion of learning the the Galler Spacing Technique (GST), the dentist will feel comfortable and confident in performing necessary IPR on any patient at any time, in any given situation.
8
THEORY
One of the most common malocclusions seen in adult dentitions is crowding. This can present as overlapped or rotated teeth in the anterior mandible or maxilla. (Figure 1 and 2)
1
.
2
Crowding results when there is inadequate intra-arch space available to accommodate the mesio-disto width of all of the teeth in the the respective arch. arch. Correcting this crowding is a main goal of orthodontics and cosmetic dentistry. There can be underlying skeletal abnormalities or jaw shape/ size discrepancies that contribute to this malocclusion. 9
There are generally 4 ways to correct crowding: crowdi ng: 1) Distalization, 2) Expansion/Proclination 3) Extraction 4) IPR. One or a combination of these methods is generally used to correct a crowded malocclusion. For the purposes of this manual, we will not include cases where surgical or prosthodontic intervention is necessary. Distalization is often used to treat t reat adolescent dentition when an
underlying Class II or Class III molar relationship is present. present. Here, the corresponding upper or lower teeth in the arch are moved posteriorly towards the distal to establish a more ideal Class I molar relationship relationship (Figure 3). More space is created created in the arch thus more room is available to align and level all of the teeth in the anterior anterior region. Distalization is generally used with fixed appliance therapy.
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Expansion and Proclination refer to increasing the width of the
arch to accommodate accommodate the teeth. teeth. For example, picture picture the mandibular or maxillary arch as a semicircle, here the circumference dictates how much room there is for the respective teeth (Figure 4). IF Diameter = 1
IF Diameter = 2
Then Circumference =
Then Circumference =
3.14
6.28
C=πD
C=πD
We know that the circumference(C) of a circle is equal to Pi (π) multiplied by the diameter (D) of that circle (C=π D). Therefore, if we increase the diameter of that circle we will increase the corresponding circumference by a factor of π. Simply put, when 11
we expand or procline teeth within an arch we are increasing the amount of space present in that arch. arch. The additional space space created can be used to alleviate alleviate dental crowding. (FIGURE 5)
Extraction can also be used to create more space in the dental
arch. Removing a tooth in an overly crowded dental arch will immediately alleviate the problem (Figure 6). The space created by the removal of a tooth can be utilized by the adjacent teeth. Surrounding teeth can rotate, shift, and gravitate into the new area.
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InterProximal Reduction can also be used to correct crowding by
creating more space in an arch. This space is achieved through the reduction of tooth enamel enamel interproximally. For example, if there is .5mm of overlap present among several teeth in the anterior, needed space to relieve this crowding can be created by removing .1mm of interproximal enamel on several teeth in the region. The teeth can then be rotated or pushed into their proper alignment. There are many tools and techniques that can be used to ‘strip’ a portion of the enamel from the teeth. It is the mastery
of the proper tools and techniques for IPR that gives giv es the dentist a very significant advantage in treating cases involving minor orthodontic corrections. There are many clinical applications for IPR — the most common being for the correction of crowded dentition. Other applications as they relate to clear aligner technology will also be reviewed in the “Clinical Applications” section of this book.
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COMPLICATIONS As previously mentioned the second most common cause of failure in minor orthodontic movement therapy is insufficient or improperly performed IPR. With such a significant potential potential for error, it is not surprising that many dentists tend to shy away from using IPR. This mindset, however, is the wrong approach; because the advantages of proper IPR use are not no t only important, but can be vital to predictable predictable teeth teeth movement. Instead, the approach should focus on devising a more reliable and precise system to performing IPR by using the proper tools and the Galler Spacing Technique (GST). Let’s briefly review some of the more common pitfalls pitfall s involved with improper IPR technique. Incorrect Reduction
The process of IPR is very technique sensitive — even minor imprecision in enamel reduction can lead to a wide array of problems. This can include over reduction and and under reduction reduction of the corresponding area. For example— If a case requires .4mm of reduction between teeth #21 and #22 and the dentist removes .6mm of enamel, there will be residual space left in between the teeth at the end of
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treatment. That space can become a cosmetic cosmetic problem or an area of open contact and food impaction. Likewise, if the dentist reduces only .3mm interproximally there will be insufficient space for proper alignment and the teeth will contact prematurely, thus some crowding will remain. Iatrogenic
It is also very possible for the dentist to cause harm to the patient or to the teeth inadvertently. This can involve damaging the adjacent soft tissues such as the tongue, gingiva or cheek. Cutting one of these unintentionally during the process of IPR can cause a lot of unnecessary pain and discomfort to the patient. One of the worst possible scenarios that can happen with IPR is ledging. Ledging occurs when the dentist gouges the tooth and creates a defect in the enamel. enamel. Instead of simply removing enamel along the long axis of the tooth, a “ledge” is created interproximally and and the tooth will need restorative repair. (Figure 7)
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Changing Contours of the Tooth
Each tooth has a specific anatomy and contours that gives it that these proportions and measurements measurements are “natural look”. Keeping these absolutely essential essential to any cosmetic case. When these principles have been compromised, teeth can often appear unaesthetic and become troublesome. If IPR is performed incorrectly, it is very easy to remove essential tooth structure. Removing a tooth’s natural line angles can greatly compromise the cosmetic appearance of that tooth — this happens frequently when dentists use high speed handpieces to relieve overlapped teeth. teeth. In an attempt to remove the contact contact points of several teeth, dentists often will wil l access through the tooth’s buccal or lingual walls with a high speed handpiece and
bur. (Figure 8)
Destruction Destruct ion of Tooth Tooth Contour Cont our Buccal
Tooth #24
Tooth #25
Lingual
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This can result in the inadvertent loss of essential tooth structure and contours. Unfortunately, this loss can never be reacquired or at least not easily. Regardless of how straight straight and aligned aligned the teeth may become, the final case will never regain its natural esthetic qualities.
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CURRENT TOOLS AND TECHNIQUES All of the challenges that we face with IPR today stem from the tools and techniques techniques that we use to create space in the arch. The theory and physics are sound, but it’s the current instruments and their methods of implementation that are actually part of the problem. Once different tools and techniques are established that help us to avoid all of the current pitfalls and apparent dangers associated with the procedure, then can IPR become the central focus for achieving space in any minor orthodontic movement case. Let’s review the three most commonly used tools for IPR today —
The high speed handpiece
The low speed handpiece
Finishing strips
High speed Handpiece
One of the most popular methods for performing IPR is to use a bur on a high speed handpiece. A groove is cut in between the teeth to open the required space. There are several major problems that plague dentists who employ this technique. The most serious of which is ledging. 18
Because there is a constant cutting capability with the high speed bur, the potential for damaging the adjacent teeth is very possible. This often occurs when attempting attempting to perform IPR between teeth that are overlapped. Another problem encountered with the high speed handpiece, is that it is ‘one size fits all.’ A good practitioner needs the ability to create anywhere between .1mm and .5mm of interproximal space. While employing the high speed handpiece, it is difficult to create varying amounts of space. Since the thinnest thinnest part of the bur must pass freely through the contact con tact point to create the opening, the dentist is limited to the thickness and size of the bur tip. Thus, if the thickness of the bur is .4mm, the dentist will automatically create a minimum .4mm opening in every interproximal space! Also, patient comfort can be compromised. There is significant noise and vibration generated by the dental handpiece and that can serve as as a source of anxiety anxiety and discomfort to the patient. As mentioned previously, for minor orthodontic movement to be widely accepted, the process and associated procedures should be as non-invasive and pain-free as possible. Low Speed Handpiece
Another common tool for IPR is a rotating disc or file on a low speed handpiece. This technique is loaded with potential hazards and problems that are similar to many of the complications mentioned above inherent to the high speed handpiece and bur.
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Due to the end cutting nature of a spinning disc it is quite simple to ‘slice’ the side of the tooth. This frequently occurs when
stripping teeth that are overlapped. However, the most difficult part of using a low speed handpiece and rotating disc is the awkwardness and hazards(!) associated with handling a straight straight nose cone cone inside the mouth. mouth. There are not many procedures which indicate the use of the straight nose cone intraorally. Not only is it awkward and difficult difficult to maneuver, but there’s also significant potential to “nick” th e soft tissues adjacent to the teeth being being reduced. This can include the tongue, gingival and buccal buccal mucosa, and the borders of the lips. If the soft tissue is cut, the visit can be a painful experience for the patient and a stressful (and messy!) one for the doctor. Finishing Strips
The third most notable tool in use today for IPR is a long finishing or polishing strip to break the interproximal contact. The best feature of this method is that there is no possibility of ledging the neighboring teeth. teeth. The strips are strictly side-cutting and and pose no threat of damaging the adjacent teeth. The biggest problem with strips is that they can only cut minimal amounts of tooth tooth structure. Due to the limitations limitations of the grit grit of each strip, it is considered a near n ear impossibility to achieve an opening of more than .15mm. This restricts the dentist in many of the uses of IPR if larger openings are needed.
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This method, though safe and simple is also very time-consuming. Much valuable chair time and energy are expended to create even the smallest of openings. And, for the reasons listed above this technique is very limited and only applicable when minute IPR is needed.
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Goals of IPR All of these shortcomings point towards the need for a new system that does not rely on these particular tools and techniques. Considering these factors, it’s obvious that a new , better IPR system is greatly needed. Now that we’ve reviewed the disadvantages of the current commonly used IPR tools, l et’s review the necessary and desirable characteristics we would want in the new “ideal” IPR system :
We would like a system that makes it impossible to ledge or damage damage the adjacent adjacent teeth. It should be side-cutting; give the dentist good control and preserve the cosmetic integrity of the treated teeth.
We need a system that is very safe and that won’t damage the surrounding soft tissues. tissues. We want to be as concern-free and as anxiety-free as possible and not have to worry about injuring the adjacent gums, cheek, lips or mucosa. And, we want want to ensure a quick and comfortable visit for the patient.
An ideal IPR tool should be easy to handle, straightforward to use and also dependable. We need a system and method that are simple s imple and safe to use even in difficult spots like in between overlapped teeth.
We want to be able to perform IPR precisely and concisely. For this, the system should have a built-in ability to control the exact amount of interproximal 22
space created. created. And, a system system with an an inherent capacity to avoid the potential for over reduction and under reduction of the teeth is critical.
We want a device that is preferably handheld and dentist-controlled. It should be easy to handle, safe for the doctor and patient and as a s unencumbersome to the dental visit as possible.
It should give the dentist the ability to produce a range of interproximal openings and thus allow the practitioner increased versatility and efficiency.
The system and tools should be inexpensive, i nexpensive, easy to sterilize, simple to store, and cost-effective.
If all of of these characteristics can be encompassed in a single IPR system, then a truly uncomplicated, precise and concise, stressfree and anxiety-free IPR visit is finally possible.
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Topical Anesthetic The procedure of IPR is often one that will irritate the gingiva of the patient. Regardless of any technique used, the gingival area is susceptible to being cut or ‘poked’ by the instrument being used.
The ginigiva around crowded teeth is usually inflamed hyperemic and sensitive. It is therefore imperative to employ some form of anesthetic for the patient. Using regular injection anesthetic to anesthetize the area is frowned upon. The discomfort caused to the patient is a problem and the resultant anesthesia is more than is i s truly needed. Popular topical anesthetics are often messy and not very effective. The most common form is 2.5% Benzocaine. This is often insufficient and has a very short working time. There is a pharmacy in New York that makes a gel called IPR GEL. It is composed of 10% Lidocaine, %10 Prilocaine, and 4% Tetracaine. This combination is extremely potent. Simply place some of the gel on the gingiva of the area that needs n eeds IPR, and after 5 minutes the the area will be completely anesthetized. This will allow the practitioner to safely and efficiently perform IPR without the patient experiencing any discomfort.
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Topical Anesthetic
BEST ON MARKET IP R G E L
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10% Lidocaine 10% Prilocaine 4%Tetracaine
New Utrecht Pharmacy New Yo Yor k
718-436-9300
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Galler Spacing Technique After having discussed the ideal system and goals, we need to find materials and a system that meets those requirements. There are many products on the market that can be used. GST relies on a combination of two products that creates the easiest and most predictable results. The products are different strips that are used by hand to create space in between teeth. They are abrasive along the sides. When passed between teeth, they will remove enamel from the surrounding teeth. They come in different sizes and grit. Their mechanism of action is to remove r emove friction in between teeth. As the abrasive side rubs against the tooth, it removes a very fine layer of enamel. This in turn creates space between adjacent teeth. They are not end-cutting and the “edge” is completely smooth. This will totally eliminate the possibility of ledging a tooth. Simply put, they can not cut in a downward motion! They cut simply by rubbing against a surface of the tooth. They are manufactured in increasing size of thickness and increasing grit. Therefore, as one moves up the sequence from least coarse to most coarse, the metal is actually getting thicker and the grit is getting coarser. Increasing thickness allows the practitioner to constantly sense the size of the space being created. At each level, the new ‘strip’ engages tightly into the
contact. This creates a simple measuring technique that eliminates the need for a separate measuring device. Knowing the space created by each residual strip provides, in effect, its own built in gauge. Now, the doctor simply needs to follow the sequence until he/she creates the desired opening (previously calculated) to solve the crowding in the arch. 26
For example, after mastering the GST, one knows that if a .2mm space if desired, the practitioner needs to have a RED IDEAL STRIP pass through the contact point. Increasing grit allows the practitioner to cut enamel at each level. As a coarse file, is passed through a tight opening, the t he abrasive sides of the strip removes enamel, this in turn creates the corresponding larger space desired. Simply following the sequence of strips allows the practitioner to easily create any space deemed necessary.
The two products are Qwik Strips made Dr Louie Khouri and Ideal Ortho Strips invented by Dr Steven Navarro. QWIK STRIPS AND IDEAL STRIPS STARTERS
FINISHERS
Neither of these products were manufactured to be used in the manner that GST calls for. However, they are easy and effective to use.
We will break up our treatment into two phases:
Phase One creates the initial opening in a very conservative and delicate way using Qwik Strips.
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d esired amount efficiently using the Phase Two bring the opening to the desired IDEAL Ortho Strips. QWIK STRIPS
Qwik Strips are manufactured with abrasive sand paper along the sides. There is an even smooth grit that allows for very easy cutting in even the tightest contact. The YELLOW- least coarse- size will fit into virtually any contact, even if they are tightly overlapped. Because they are not end cutting, there is no possibility of ledging when using them interproximally. The friction of their abrasive side against tooth structure removes a very fine amount of enamel. They are manufactured in single sided, double sided and curved configuration. In the Galler Spacing Technique, one only utilizes the single sided strip. This strip slides easily into any potential interproximal area and makes spacing very simple. The double sided strips are not as efficient at removing large bulk tooth structure as their counterparts- the IDEAL strips. It is for this reason that we use the single sided Qwik Strips to start the process, and the double sided IDEAL strips to
create the larger spaces. Qwik Strips excel at getting into very tight contacts where access is difficult. Their easy design and comfortable grip allow the dentist to easily slide them ini nbetween any contacts. The abrasive side removes tooth structure which in turn creates the desired opening. Using them in sequence from YELLOW-RED-BLUEGREEN will create an opening of just under .1mm. Although that amount of space seems insignificant with regards to a crowded dental arch, it allows the doctor to have easy access to the contact area with the larger more efficient tools. IDEAL Strips
IDEAL strips are manufactured to be put into a reciprocating handpiece that slices in between teeth. Disadvantages of using the motor system are that firstly, one 28
loses the manual dexterity in feeling the space opening at each level of grit and secondly, the cumbersome nature of the handpiece adds anxiety to the patient and makes it difficult to maneuver. IDEAL Strips are available in 7 different increasing sizes of thickness and grit. This allows the practitioner to increase the size of the space simply by following the sequence. Each time a new ‘strip’ is used in the sequence, the practitioner practitioner feels friction
owing to the increasing size of metal thickness. The increasing coarseness of grit allows the practitioner to remove ever increasing layers of enamel. The overall result is a very controlled way to remove enamel in a neat orderly efficient manner. There is no possibility of damage to collateral tooth structure because the ‘strips’ will only remove enamel based on friction. Once the friction is
no longer present they will not remove enamel. This eliminates the common complication of excess tooth structure being removed When used properly they will accurately tell you how big the corresponding aperture is. This can be determined by studying the color of the strip that can pass freely in the contact without binding. Therefore, use of a cumbersome, timeconsuming gauge becomes obsolete. (FIGURE 11)
IPR BEFORE AND AFTER
0.4mm
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STEP BY STEP PROCESS PHASE ONE
THE STARTERS:
1) The system uses the Qwik Strips to start the process.
2) These are taken in the dentists hand and gripped in a thumb forefinger grasp.
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3) THEY COME IN FOUR DIFFERENT SIZES: a. YELLOW YELLOW-- LEAST COURSE b. RED RED-- MEDIUM COARSE c. BLUE BLUE-- MORE COARSE d. GREEN GREEN-- MOST COARSE 4) THEY ALSO HAVE: a. SINGLE SIDED (preferred) b. DOUBLE SIDED c. CURVED SINGLE SIDED
VARIETY
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STEP ONE: DETERMINE THE AMOUNT OF SPACE NEEDED INTERPROXIMALLY
STEP TWO: APPLY TOPICAL ANESTHETIC TO PAPILLA AND SURROUNDING GINGIVA
STEP THREE: GRIPPING THE SINGLE SIDED YELLOW QWIK STRIP WITH THUMB-FOREFINGER, PASS GENTLY THROUGH THE CONTACT OF THE TOOTH. ONCE THERE IS NO RESISTANCE, STOP! (You do not need to continuously sand the tooth once there is no friction!)
Yellow QWIK QWI K STRIP
STEP FOUR: GRIPPING THE SINGLE SIDED RED QWIK STRIP WITH THUMB-FOREFINGER, PASS GENTLY THROUGH THE CONTACT OF THE
Red QWIK STRIP
TOOTH. ONCE THERE IS NO RESISTANCE, STOP!
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STEP FIVE: GRIPPING THE SINGLE SIDED BLUE QWIK STRIP WITH THUMB-FOREFINGER, PASS GENTLY THROUGH THE CONTACT OF THE TOOTH. ONCE THERE IS NO RESISTANCE, STOP!
BLUE QWIK STRIP
STEP SIX: GRIP SINGLE SIDED GREEN QWIK STRIP AND GENTLY PASS THROUGH THE CONTACT. ONCE THERE IS NO FRICTION STOP!
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GREEN SINGLE SIDED QWIK STRIP
END PHASE ONE EVEN THE TIGHTEST CONTACT AND EVEN THE MOST OVERLAPPED TEETH ARE NOW OPEN. YOU MAY NOW PROCEED TO USE THE NEXT MATERIAL THAT WILL CREATE YOUR DESIRED OPENING. THE OPENING RIGHT NOW IS LESS THAN .1mm.
PHASE TWO Phase Two use the IDEAL Strips. These are more coarse then the Qwik Strips and cut more efficiently. They can usually not be used to start because they will not fit into tight or overlapped teeth. The Strips must be sequentially to ensure patient comfort and maximum efficiency.
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1) They come in 7 sizes: a. WHITE- CREATES A .1MM OPENING (Least Coarse) b. YELLOW YELLOW-- CREATES A .15 MM OPENING c. RED – CREATES A .2MM OPENING d. GRAY – CREATES A .3MM OPENING e. GREEN GREEN-- CREATES A .4MM OPENING f. BLACK- CREATES A .45MM OPENING g. BLUE BLUE-- CREATES A .5MM OPENING (MOST COARSE)
2) They are available in only Double-Sided. They were designed to fit into a slow speed handpiece, but work excellently when gripped with fingers.
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STEP ONE:
36
Grip the WHITE Ideal Strip between the forefinger and thumb and pass through the contact gently. Stop when there is no FRICTION. DO NOT SAND THE TOOTH CONTINOUSLY.
THE INTERPROXIMAL AREA NOW MEASURES EXACTLY .1mm EVERYTIME!!
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STEP TWO:
Now grip the YELLOW IDEAL Strip in thumb-forefinger and pass through the contact until there is no friction present. This will create a .15mm opening.
STEP THREE:
Grip the RED IDEAL Strip and pass through th rough contact till there is no resistance. The interproximal space is now an EXACT .2mm opening. 38
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STEP FOUR:
If desired space is .3mm continue with GRAY IDEAL Strip.
STEP FIVE:
If desired opening is .4mm continue with Green Ideal Strip. This might require a little bit of pressure to help to create this
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space. In this step only, additional cutting can be accomplished by leaning the GREEN IDEAL instrument against the tooth.
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STEP SIX AND SEVEN:
Continuing with the BLACK and then the BLUE Ideal Strips will give you the desired .5mm opening. END OF PHASE TWO IPR.
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Discussion: At this point, the dentist has achieved the space required to aid in minor orthodontic movement. There is no possibility of ledging since the instruments are not end-cutting. They can be used between any overlapped teeth at any time. There is no concern over any damage to surrounding tissues, or excessive destruction of tooth or enamel. Using these tools is one way to create fast, effective, low risk IPR. In practicality, the Qwik Strips wear out after 1-2 1- 2 patients and should then be discarded. They should be disinfected and autoclaved after each use. When the grit on the tool appears faded away it is no longer effective and should be discarded. Sometimes, when the contacts between the teeth are very light, the practitioner may be able to start phase one using the Blue Qwik Strip, instead of the Yellow Qwik Strip. The IDEAL Strip can be used on 2-3 patients depending on the amount of IPR performed. They should be disinfected and autoclaved after each use. The WHITE (.1mm) strip usually usu ally exhibits the most amount of wear and bends after excessive use. If the metal grip bends or breaks, the tool should be discarded immediately.
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There is no set way to grip the IDEAL strips, they may be gripped in thumb-forefinger manner lengthwise, or like a hatchet by gripping the handle with thumb forefinger.
It is critical to remember that the strips must be used in incremental fashion. One cannot, start in the middle of the sequence; you must use all the files in order, from least coarse to most coarse. Because the strips do not bend, there is no possibility of removing collateral tooth structure. The strips will only cut where t here is contact in between the teeth. When there is no contact in between teeth the strips will not cut. They will, therefore, not inadvertently remove line angles and other key components of tooth anatomy. We had previously mentioned that one of the complications of improper IPR was changing the contour of the tooth. By learning the sizes and corresponding color schemes of the various strips, one can eliminate the need for a separate measuring gauge. With GST, one can safely s afely open contacts between teeth without risk of damaging soft tissue and changing tooth contour and form.
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