Protocol for the finishing stage

Finishing is the most effective weapon in the battle against relapse. The choice of method depends on analyzing the type of relapse that is feared and the impact of aging, and on the help to be expected with retention. The present article deals with the practical requirements of finishing: duration, pre-finishing assess-ment, final arch wire bending, possible occlusal buffing, and elastic vertical interarcade traction. The theoretic protocol is illustrated by 3 cases followed up through finishing until appliance removal. The stability of occlusal results of course depends on the accuracy and fineness of finishing, but also on overall treatment management: anterior dentition control, anchorage control during retraction period, and choice of devices and extractions. Finishing can thus be said to be an important step - but one that begins on the first day of treatment.


INTRODUCTION
There are few studies with high levels of evidence.
Many studies implicated occasional effects 3 , for example, of a certain treatment attitude, clinical choice, atypical growth, physiological or anatomic problem, etc. Such reports are often incomplete or low on level of evidence, but it is certainly helpful to take them on board in our therapeutic behavior.
Finishing differs from the main work in its timing (last touches), limited extent and, in our opinion, prime importance. Finishing is not a subsidiary but a major step.

J. FAURE
A perfectly finished program requires precautions taken during the main work itself, as mistakes cannot always be rectified by finishing. "Perfect" finishing in orthodontics thus depends on: -initial treatment choices (control of anchorage, choice of extractions), -and finishing itself.
In what follows, we shall briefly present our choices, the material procedures of finishing and their timing, richly illustrated from case reports.
We shall not enter into the intricacies of defining ideal occlusion, leaving the reader to refer to the criteria of the American Board of Orthodontics Grading System 1 , which seem to command consensus in static terms.
Consecrating 6 months of treatment, with 4 or 5 appointments, is surely not excessive to deal in detail with static and dynamic occlusion: Poling 9 advises 4 to 7 months. But this must not prolong the total treatment duration: to have 6 months for finishing, the other steps need to be performed as quickly as possible. Time-saving should begin from the outset of multibracket treatment, so as to achieve molar and canine class I relations with 2 mm incisor overbite, perfect alignment and leveling and closed spaces within a year and a half at most. The patient will then accept 6 months' finishing without objection.
Functional and dynamic imperatives and esthetic criteria, on the other hand, are not well-defined.
Our approach to perfect finishing consists in balancing the patient's maxillofacial architecture, especially anterior dentition, as well as possible, respecting the recognized rules of occlusal dynamics, and adopting a cautious attitude toward known threats to stability of treatment: third molar progression, anterior interdental dysharmony, late growth, etc. 3 We shall then focus on our efforts to refine static occlusion.
To this aim, we present our finishing protocol.
Thus rapidly achieving good "prefinishing" occlusion is the first step toward perfectly "finished" occlusion.
The transition to the finishing stage involves a break in the practitioner's concerns: where we had been concerned with the main aspects of objective occlusion, we now turn to what is more esthetically and functionally important: intercuspation, incisor alignment adjustment, artistic deformation, refining canine class I, adjusting the canine guide, etc. We need to look at what has been achieved, plan the finishing work and take account of how long treatment has already lasted and how much cooperation can be expected of the patient, in order to estimate how much time we can reasonably allow for finishing.

GENERAL LINES
One major function of finishing is to test the quality of malocclusion correction. Otherwise, there is a risk of removing devices as soon as they seem to have triumphed over class II and signs of class I occlusion are observed. Unfortunately, however, this is often just a case of "Sunday bite" induced by the maxillomandibular elastic bands and, no sooner have the devices been removed than the patient slips right back into class II with severe overjet.
Unfortunately, in some cases the finishing stage cannot be strictly defined: finishing work on the arch is required during the anterior retraction stage (case n° 1) to help correct malocclusion.

Analysis of occlusion status and finishing strategy
In our opinion, occlusion analysis does not require a complicated clinical form, but does include: -static aspect, with articulating paper to trace the numerous contacts and intercuspal balance; -dynamic aspect, with systematic examination of lateralities and especially propulsion.
For us, analysis of occlusion defects is in strict parallel to correction, systematizing intervention and avoiding a lot of points getting overlooked.
A radiological check-up is essential. A panoramic view serves to check tooth parallelism and excessive interroot space if implant sites are to be prepared. It also avoids corono-radicular angles being detected too late when they might lead to threatening proximities: treatment in this case (figs 1-6) of severe class III, ended with perfect occlusion, with a slight linear and angular mandibular compensation that had to be accepted, and maxillary decompensation that doubtless ensured anterior stability; systematic end-of-treatment panoramic unfortunately showed severe mandibular canine angulation; it was too late to correct the tooth axes to achieve compromise after the devices had been removed.       The main therapeutic procedures comprise: -elastic vertical traction, worn permanently. Traction should be exerted on the arch (welded brass spurs or pinched stops) rather than on this or that tooth: unitary dental displacement is governed by the arch (especially 2 nd order shaping), whereas maxillomandibular traction controls extensive gaps (dental group or arcade sector or half-arcade). Arch anchorages may seem to hinder implementing shaping at the same site, but this is not actually true: angulations can be introduced on either side of the weld without putting its at risk, to perform a step, for example ( fig. 7). -Occlusal sharpening regularizes anatomic abnormalities hindering occlusion. Occlusal adjustment should not replace finishing, often by inducing dental intrusion or extrusion in case of gauge error; buffing is indicated in coronary dysmorphism causing a gap or occlusal trauma. -Shaping on .019 x .026 arch, by 139type forceps, is certainly the most precise method, enabling any practitioner to perform a release on the arch with 0.2 mm precision; it is the method we prefer. Poling 9 underlined the risk of weakening the arch at the torsion points, but we think the risk of fracture is virtually non-existent.
Some authors recommend an alternative solution, ungluing and regluing the bracket when badly positioned. This is attractive, being in line with the philosophy of a straight arch, but is open to theoretical and practical objections: -If 13 shows 0.5 mm extrusion and 5° tip-forward, the bracket should be released and reglued with a 0.5-mm shorter gauge and in-built 5° tip-back. The problem is that, once the original bracket has been released, we have no reference for positioning the new one! "ungluing-gluing" as recommended by some: this is the spread of selfligating brackets (which we have used for many years now); time saving compared to ablating and replacing an arch now leaves more time for "touching up" and a strategy of rational finishing (notably respecting the rule of the 3 orders) conducted methodically and rigorously. No-one would hesitate now to remove a terminal arch with a single application of pliers.

Main treatment procedures
-Experience shows that practitioners usually glue the second bracket back precisely in the position of the first, exactly matching the anatomic data at first fitting 9 . -The smaller the desired change in position, the less the precision of correction by regluing 9 . We consider the "ungluing-regluing" method indicated only for big mistakes in positioning (>1.5 mm), which almost never happen.
Another argument supports the choice of "pliers shaping" rather than At each stage, of course, we check the result of the previous stage, statically and dynamically; the protocol can be revised at any time.

Hierarchy of interventions on the arch
Intervention should follow a rigorous protocol. Three chronological rules are to be observed -intervention according to arcade: first intervention on mandibular arcade, then on maxillary arcade; -intervention according to order: first, 1 st order; second, 2 nd order; third, 3 rd order; Some schools recommend "loosening the bridle" during finishing, using more elastic material and under-sized arches in titanium or nickel-titanium of .018 x .025 or .016 x .022 section or round .016 or .014 arches, in the hope that nature will finish occlusion.
-intervention according to extension or location: first intervention for a general problem; second intervention for a localized problem.
For example, in case of bilateral tip-to-tip, with clear crossed occlusion only in 14/44-45 and 25/35-36, we begin by overall maxillary expansion (and possibly mandibular contraction); then secondly we correct remaining crossed occlusions by individual inset/offset procedures.
In contrast, we think that, near the end of treatment, position control needs to be maintained or increased to correct the last remaining little imperfections.
Finishing thus uses .019 x .026 nickelchromium arches in 95% of cases. We only use full-groove arches for severe general problems of arcade shape.
Transversally, bilateral crossed occlusion problems can be easily resolved by maxillary expansion or mandibular contraction or both, with either a .022 x .028 active arch or 2 arches.
Vertically, in case of strong mandibular Spee curve, a full-groove arch solves the problem quickly.
Steel arch, section .019 x .026 A .019 x .026 arch has the advantage of enabling most finishing corrections to be performed in a single procedure, without risk of bracket detachment.
It is possible to introduce 1 st or 2 nd order shaping in the arch up to 1 to 1.5 mm (step-up/step-down or inset/offset ).
Shaping on this scale with a fullgroove arch would inevitably lead to detachment.
But it can also be introduced in 2 stages ( fig. 8: 0.75 mm step, increased to 1.5 mm at next appointment).
The .019 x .026 arch is the optimal compromise between malleability and elasticity for occasional finishing.
Moreover, loss of position control is minimal with a.019 x .026 arch in a .022 x .028 groove: negligible for axial rotation or mesio-distal tilt, and only 7° for torque.
If the power of a full-groove arch is needed (e.g., strong Spee curve), it should be introduced first, and then, for occasional finishing, either revert to a .019 x .026 arch or finish with a full-groove arch in 2 stages (cf. below and fig. 8).
The frequency of finishing operations depends on the large number of occlusal contacts. Ranking according to order is as follows: 2 nd order: approx. 70% These are general interventions, notably correction of strong Spee curves; they are often occasional, especially to intrude/extrude single teeth in the lateral sectors (step-up or stepdown); axial corrections (tip back/tip forward, with 2 identical consecutive steps) are more frequent in the anterior sector, for esthetic reasons, optimizing the "esthetic shaping" already included in the brackets.
Occasional interventions are rarer: slight vestibular or palatal displacement (offset + inset » or inset + offset), to correct, for example, an overly vestibular lateral, incisor (residual class II division 2 occlusion), or axial rotation due to general gluing error (inset + inset or offset + offset ).

rd order: exceptional
Third-order intervention is very rare in our practice. Torque control with a .019 x .026 arch in a .022 x .028 groove is excellent, with just 7° play or loss of control. mended by some authors (Planché, Andrews) to guard against any slight tendency to relapse. Such angular overdecompensation comes obviously at the price of linear over-compensation; likewise, over-decompensation of bilabioversion requires reduced superior and inferior incisor torque.
Occasional intervention may exceptionally be needed to correct ectopic included canines that have undergone difficult traction (e.g., vestibular maxillary canines) to avoid fenestration. In such cases, it is wise to provide "torque breakers" to soften, the impact of torque correction.
These rare interventions usually concern incisor groups, to achieve angular under-compensation or overdecompensation. What is sought is a final position in angular over-decompensation: in severe skeletal class II, for example, final slight incisor angular superior protrusion (+3° to +5°) and slight inferior retrusion (-3° to -5°), or class III compensation, is recom-A long finishing stage using pliers provides perfect static occlusion, rigorous intercuspation and canine and molar class I relations, while ensuring functional and esthetic excellence.
This stage is not enough in itself to ensure stability, which depends also on the architectural balance of the face and anterior dentition: i.e., the critical therapeutic choices regarding extraction and mechanics, anchorage, final incisor positioning and functional balance, etc. Thus, finishing begins on the day when the brackets are fitted; the first steps are critical as initial mistakes preclude perfect occlusion, and any delay leaves less time for finishing.
Even with perfect treatment strategy and rigorous finishing, definitive stability is not guaranteed, and final occlusion may "wobble" , either for functional reasons (recurrent dysfunction) or simply with aging.
Even so, a rigorous protocol, close attention and time spent on finishing help conjure the specter of relapse, or at least reduce its frequency and severity.
Manon G. consulted in May 2011 at the age of 13 years 8 months. Her face presented as class II hyperdivergent; intraoral examination, however, found molar class I with only moderate overjet (figs 9-12). Cephalometry confirmed the severity of skeletal class II, "borderline surgical" , and the degree of linear and especially angular compensation trying to hide it. Bilabioversion related to DMD was superimposed on class II (T1 and T2) linear compensation.

CASE 1
Diagnosis      The incisor positioning objective involved a very slight compromise to balance a difficult "frame" , at the cost of heavy devices (miniscrews to avoid any loss of anchorage) in a difficult case (figs 14 and 15).
Achieving perfectly finished stable occlusion required extreme mechani-cal precautions to maintain anchorage, enabling rigorous control of skeletal and dental class II correction and correction of linear bilabioversion.
We used straight arch attachments, with.022 x .028 groove, Roth prescription and inbuilt -10° and -15° tip--back on the mandibular molars (passive self-ligating brackets).    Aug. 2011 (13yrs 11mo) -Aug. 2014 (16yrs 11mo) The degree of anterior retraction to be achieved, especially on the maxilla, required early finishing operations, during the actual retraction stage, although we would usually try to avoid this. Finishing will optimally adjust occlusion when malocclusion correction has been completed.
Early finishing operations were needed as incisor retraction was blocked by closed bite (figs 16 and 17), due to slight excess of maxillary incisors gauge and arcade flexion induced by the retraction imposed (.019 x .026 arch); reshaping comprised 2nd order action (maxillary incisor intrusion, especially of 11-21) and radiculo-palatal torque (figs 18-21).              Facial examination found class III with notable cheek-bone aplasia ( fig. 28).

Treatment and finishing:
Intra-oral examination confirmed this impression, with slight molar class III, despite overjet in 11-21, due to crowding (fig. 29). Cephalometry (figs 31 and 32) confirmed slight hyperdivergent CASE 2 Diagnosis Figure    class III and strong bilabioversion, reducing, as is often the case, the sensation of slight skeletal dysmorphism and "saving" the class III.
Bilabioversion was stronger in the maxilla than mandible, due to class III compensations superimposed on the bilabioversion.   Straight arch attachments with Roth prescription and -10° and -15° built-in tip-back on mandibular molars improved anchorage (passive selfligating brackets).
An anterior alignment-advancement plan was abandoned, mainly due to the vertical problem: anterior balance would have been precarious.  A second-premolar extraction strategy avoided strong incisor retraction, while balancing the anterior box; the permitted anchorage loss should be of good prognosis for 3 rd molar "salvage" ( fig. 55 and 56).

Treatment plan
The patient was fitted with straight arch brackets with Roth prescription and built-in -10° and -15° mandibular molar tip-back for better anchorage control (passive self-ligating brackets).
Multibracket treatment was begun in April 2012 (14 years 3     The photographs of the terminal arches show the finishing results (figs 61-65): mainly 2 nd order interventions (step, Spee curve, accentuated in maxilla and inverted in mandible, tip-forward on 21, intrusion step-down molar groups with a slight gauge excess etc.) but also 3rd order (reduction of superior incisor torque).      Third-molar progression will be followed up ( fig. 71).

J. FAURE
Retention comprises a transparent maxillary splint and a metal wire glued to the mandibular ar-cade from 33 to 43 (figs 72 and 73).