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Clinical use of custom-made transpalatal arches--why and how

Article  in  World Journal of Orthodontics · February 2004

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Björn U Zachrisson
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T H I N G S Y O U W A N T T O K N O W

Clinical Use of Custom-Made

Transpalatal Arches—Why and How
Some time ago, I started to use the Zachrisson-type transpalatal arch design in
my practice, and I have found that it really works. Particularly in vertical cases
with severely rotated molars, the custom-made design appears preferable to
the standard preformed Goshgarian-type transpalatal arches. Most of the time,
I use an indirect approach for its fabrication. It would be interesting to learn
why and how you came up with your design for the customized version, and get
some practical tips on the preferred method to make and bend it. Can you also
provide some theoretical considerations regarding the usefulness of
transpalatal arches in clinical practice?
—Frank Weiland, Deutschlandsberg, Austria

BJÖRN U. ZACHRISSON, OSLO, NORWAY

Advantages of the custom-made transpalatal arch
As stated elsewhere,1 the custom-made transpalatal arch2,3 (TPA) is fundamen-
tal in my treatment technique. I have used it with almost every patient I have
treated over the past 10 years. The design with one large anterior and two
smaller posterior loops (see Figs 7b, 9b, 9c, 10c) was arrived at after several
trial-and-error attempts with different loop designs. The present version
appears to be optimal for many different purposes. It is effective for (1) maxil-
lary molar derotation; (2) maxillary arch width control and lateral expansion; (3)
adding buccal root torque for maxillary first molars; (4) reinforcing posterior
anchorage; (5) vertical control of maxillary molar eruption; (6) securing and
maintaining maxillary arch form control throughout treatment; and (7) correct-
ing mesiodistal asymmetries. In Class II malocclusions in children and adoles-
cents, I use the custom-made TPA in combination with a high-pull headgear
with short outer bow to influence both the normal molar eruption and the verti-
cal growth of the midface.1,4
The main differences between my design and the traditional Goshgarian-
type TPA design are in the amount and shape of the wire in the palatal loop.
The middle loop is larger and longer than the single Coffin loop of the Goshgar-
ian arch, and two additional smaller loops are symmetrically positioned on
either side of the middle loop. The middle loop is directed mesially and the

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additional loops are directed distally. Size and adaptations are required for individual
palatal vaults. The terminal ends are longer than the standard ones to secure improved
engagement to the lingual sheaths and make safe ligations possible. Increasing the
length of the wire will increase its springiness and range, and lower the load-deflection
rate and make the forces more constant and precise.2 Compared with Goshgarian-type
arches, our design produces lower and more constant moments of derotation.2 The two
small, distally directed loops give the arch obvious flexibility, which makes the engage-
ment into the attachments easier with less activation loss. It takes less time to derotate
molars with our design than with traditional Goshgarian arches.3–5

Fabrication of the custom-made TPA

Our procedure to make and bend the custom-made TPA is as follows:

1. Fit maxillary molar bands with lingual sheaths and take alginate impression with the
bands in place.
2. Carefully place bands in impression and sticky wax bands in place. Add a thin layer of
wax on the inside of the bands, and pour impression with plaster or stone.
3. Measure distance between sheaths along the palatal contour with brass wire (Fig 1a),
and use a standard Goshgarian arch as template while bending the 0.036-inch Blue
Elgiloy wire.
4. Start bending the arch blank in one terminal end using an Adams 135L pliers (Den-
tronix, Ivyland, PA, USA) (Fig 1b), and use two such pliers to squeeze the double ends
really tight (Fig 1c).
5. Use bird beak pliers to shape the first distal loop (Fig 2a) and then the mesial loop (Fig
2b). Repeat for the other side to produce the arch blank (Fig 2c).
6. After the blanks are formed, the palatal curve is placed with thin three-jaw pliers (Fig
3a). Requirements of design are minimal but extremely important. Generally, the wire
should miss the tissue by 0.5 to 1 mm; never contact the tissue (clinically indicated by
tissue blanching). Therefore, the bend indicated in Fig 3b is important to avoid gingi-
val impingement close to the molar bands. Next, the mesial loop is adapted to the
palatal vault (Fig 3c).
7. Buccal root torque and rotation bends are made with an Adams 135 L pliers (Fig 4a),
and the arch is inserted in the sheaths from the mesial (Fig 4b and 4c).
8. The most attractive part of the indirect technique is that the TPA can easily be closely
adapted to the shape of the palate by forcing the wire close to the palatal vault con-
tour with pliers (Fig 5a and 5b).
9. When adaptation is optimal, the wire is heat treated with electric cables (Fig 5c) to
minimize any stresses within the wire, while maintaining the spring in the wire. Avoid
overheating (wire should be brown, not red).
10. The wax is melted away from the bands with the electrodes on the labial and lingual
attachments (Fig 6a). The passivity of the TPA can be tested when it is loosened from
the plaster cast (Fig 6b). Finally, the inside of the bands are cleaned by microetching
with a sandblaster (Fig 6c).

Proper maxillary first molar derotation during orthodontic treatment

There are two reasons why the complete derotation of the maxillary first molars associ-
ated with orthodontic treatment of Class I and II malocclusions is important: (1) space
considerations and (2) the fact that most Class II malocclusions are more Class II on the
labial than on the lingual side (see below).

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 a b c

Fig 1 Fabrication of a custom-made TPA. (a) Measuring distance between lingual sheaths along palatal vault with brass wire. (b)
Making bends of terminal end of the 0.036-inch Blue Elgiloy wire with Adams 135 L pliers. (c) Squeezing terminal end using two
Adams 135 L pliers (one to hold the wire and the other to squeeze the ends tightly together).

a b c

Fig 2 Bending the middle loops using bird beak pliers. (a) Starting the first posterior loop. (b) Bending the large middle and the
second smaller posterior loops. (c) Arch blank. The distance between the terminal loops corresponds to the measurement taken
with the brass wire in Fig 1a.

a b c

Fig 3 Using thin three-jaw pliers for adapting the TPA to the contour of the palatal vault. (a) Contouring the roof of the palate. (b)
Contouring close to molar band to avoid tissue impingement. (c) Contouring large anterior loop.

a b c

Fig 4 Adaptation and insertion of the TPA. (a) Using Adams pliers to make torque and rotation bends. (b) Insertion from the
mesial aspect of the lingual sheath. (c) Pulling archwire into the lingual sheath using Adams pliers.

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 a b c

Fig 5 Adaptation and stress relief of the TPA. (a) Forcing wire with pliers to fit contour of the palatal vault. (b) The distance to the
palate should be 0.5 to 1 mm throughout the wire length. (c) Heat treating wire with electric cables to relieve stress while main-
taining springiness.

a b c

Fig 6 Removing and cleaning the TPA. (a) Melting away wax inside bands. (b) Checking wire for passiveness. (c) Sandblasting
inside of molar bands.

a b c

Fig 7 (a) Typical mesiolingual rotation of first permanent molars (arrows) at start of orthodontic treatment of Class II, Division 1
malocclusion in young patient. Patient was treated with custom-made TPA and high-pull headgear to derotate the first molars (b)
and move them distally (c). Note that the distance from the midpalatal suture to mesiobuccal cusp of the first molars is longer than
the distance from the midpalatal suture to distobuccal cusp after proper derotation (b), whereas the reverse relationship was evi-
dent at the start (a).

When the maxillary first permanent molar drifts mesially into malocclusion, the tooth
rotates on its mesiolingual cusp.7 The large lingual root contacts the lingual cortical plate
and allows the two buccal roots to rotate mesiolingually.7 Since the occlusal surface of the
first permanent molar is trapezoidal in shape, more mesiodistal space is used in the den-
tal arch when this tooth rotates mesially on the lingual root as the axis (Fig 7a). This use of
more space in the arch by the molar is reflected in the anterior positioning of all cusps
mesial to it. Hence, if good cusp interdigitation is to be accomplished in the finished ortho-
dontic case, care must be taken to fully rotate such a molar distolingually7 (Fig 7b).
The optimal rotation of a maxillary first molar is demonstrated on a skull with ideal occlu-
sion in Fig 8b. As noticed by Stoller,7 the canine and buccal cusps of the premolars are in line
with the mesiobuccal cusps of the first molar. The buccal cusps of the second molars are in

263
 Fig 8 (a) Young patient with Class
II malocclusion and typical mesiolin-
gual rotation of permanent first
molars at the start of treatment.
Patient was treated nonextraction
with custom-made TPA, high-pull
headgear, and full fixed appliances.
Note proper derotation of the first
a molars at the end of orthodontic
treatment (d). Note the optimal first
molar rotation in the skull with ideal
occlusion (b and c). A straight piece
b c of archwire will touch the canine,
both premolars, and the mesiobuc-
cal cusp of the first molar, whereas
the buccal cusps of the second
molar are in line with the distobuc-
cal cusp of the first molar (c).
d

line with the distobuccal cusp of the first molar (Fig 8c). The change in arch form at the maxil-
lary first permanent molar gives this tooth another qualification in addition to its axial inclina-
tion and intercuspation with the mandibular molars to designate it as the key to occlusion.7,8
It is generally difficult to achieve a proper derotation of the first molars when only labial
orthodontic appliances are used. On the other hand, it is quite easy with the use of
TPAes.9 The reason for this difference is that the solidity of the heavy 0.036-inch palatal
arch dominates the labial arch force systems. Even overrotation of the molars can be eas-
ily obtained clinically by adding rotation adjustment bends in the TPA (Fig 4a).9
In an ideal occlusion, according to Ricketts,10 a line can be drawn between the disto-
buccal and mesiolingual cusps of the maxillary first molars that should transect the distal
third of the canine on the opposite side. A more practical, and clinically more precise,
guide is to measure (or eyeball) the distances from the midsagittal line on the median
raphe to the mesio- and distobuccal cusps of the molars. When the first molar is optimally
positioned, the line from the midline to the mesiobuccal cusp should be at least equal in
length, or preferably longer, than the line from the midline to the distobuccal cusp (Figs
7b, 8b to 8d, 9c).
During derotation of symmetrically rotated left and right molars by using TPAs, equal
and opposite moments of rotation will be produced without creating mesiodistal forces. In
clinical practice, however, it is impossible to produce equal moments, even if the molars
are symmetrically rotated; this means that there will generally be small, presumably clini-
cally significant, moments and forces. The force will be mesial where the moment of dero-
tation for mesially rotated molars is larger.2 However, in clinical practice, such mesial
forces can generally be effectively counteracted by the simultaneous use of a high-pull
headgear or Class II elastics.

Class II molar relationships diagnosed from the lingual

When comparing Class II molar relationships by visual inspection from the buccal and lin-
gual sides, the Class II conditions are generally more pronounced when the occlusion is
viewed from the buccal aspect.11 This is caused by the mesial rotation of the molars. In a
recent study of 459 malocclusions with mild, moderate, and severe Class II relation-
ships,11 first molar rotations were observed in more than 80% of the cases. The study con-
cluded that the buccal molar relationships were not consistent with the corresponding

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 a b c

Fig 9 The custom-made TPA is ideal as an anchorage unit for moving impacted maxillary canines into position in the dental arch.
(a) The 0.017 ⫻ 0.025-inch sectional stainless steel wire inserted in the extra tube on the first molars can provide any movement
desired of the canine. The appliance is almost invisible from the front throughout the time it takes to extrude the canine, and there
is no risk for apical root resorption on the lateral incisor (b). (c) The case at end of orthodontic treatment, with proper derotation of
the first molars, and a six-unit gold-coated 0.0215-Penta-One wire (Gold’n Braces, Palm Harbor, FL, USA) bonded lingual retainer.

lingual relationship in 90% of conventionally diagnosed Class II cases, according to

Angle’s classification. The implication of these findings is that in the majority of Class II
cases, a proper derotation of the maxillary first molars should be part of a correct and
sound treatment plan (Figs 7a to 7c).

TPA and vertical control

Together, the large mesial loop and the two smaller loops of the custom-made TPA act
similarly to the acrylic button of the TPA with a large acrylic button, dubbed the VHA (verti-
cal holding appliance).4 When the VHA is used for 1 to 2 years, there is a significant effect
due to the tongue on the vertical movement of the first molars (mean effect up to 1 mm
intrusion). It is likely that the effect of the tongue is greater on the custom-made TPA than
on a conventional Goshgarian-type arch,6 where the Coffin loop is much smaller. However,
even on a Goshgarian-type palatal arch, the effect of tongue function has been found to
be useful for vertical control of the maxillary molars.6,13–15 For Class II correction in young
patients, a high-pull headgear is used, together with the TPA, for additional vertical con-
trol. The TP bar is then used to add buccal root torque to the first molars, to derotate the
molars, and to expand the intermolar distance as required. Both the high-pull headgear
and the custom-made TPA exert intrusive effects on the molars and the maxillary complex.
The vertical control is an important ingredient in the treatment of sagittal discrepan-
cies.12,13 The explanation is that the mechanical inhibition of vertical maxillary growth
leads to a greater anterior component of the available mandibular growth.16 In addition,
the effective molar derotation obtained with the TPA plus the distally directed pull of the
headgear contribute significantly to the Class II correction.

TPA and impacted maxillary canines

The solid posterior anchorage obtained with the custom-made TPA makes it an ideal appli-
ance to bring down impacted maxillary canines. By using a sectional archwire from the
auxiliary tube on the molar band to the impacted canine (Figs 9a and 9b), one has an
effective, yet almost invisible appliance from the front (Fig 9b). The risk for undesirable
side effects, like loss of anchorage and/or deterioration of arch form, is minimal at the
same time as the molar derotation and expansion, if needed, can be effectuated (Fig 9c).
Another advantage of this set-up is that there are no counterforces on the lateral incisor,
as when full fixed appliances are used. The risk for apical root resorption on the lateral
incisor is thus eliminated.

265
 Fig 10 (a)The palatal intrusion mechan-
ics for torquing a maxillary second molar
where the palatal cusp has become too
prominent (arrow). (b) The force system.
Intrusion that is more marked palatally
and some palatal crown movement will
result.17 (Courtesy of Dr Frank Weiland,
Austria). An elastic force between a spur
a b soldered to the custom-made TPA and a
bonded cleat on the second molar (c)
achieved the desired tooth movement
(arrow in d) within 2 months.

b d

TPA and palatal intrusion mechanics

Sometimes during orthodontic treatment, after distalization of maxillary first molars or for
other reasons, the palatal cusp of the maxillary second molars becomes too prominent
(Fig 10a) or, in more extreme cases, the second molar is in buccal crossbite. Heavy bal-
ancing-side contacts will occur, which are undesirable from a functional point of view. A
combination of intrusion, buccal root torque, and lingual crown movement is needed, and
this is almost impossible to achieve simultaneously with conventional mechanics when
labial force application is used. However, the palatal intrusion technique (Fig 10b) as
described by Kucher and Weiland17 presents an efficient and simple way to correct the
position of malposed maxillary second molars. A spur is soldered to the TPA on the side
where the second molar has to be corrected, pointing distally (Fig 10c). At the level of the
second molar, the end is bent to a small hook. A cleat is bonded to the palatal surface of
the second molar. After insertion of the TPA, an elastic chain is put between the spur and
the cleat (Fig 10c). This creates a force system that is absolutely ideal for the desired
tooth movement (intrusion of the palatal cusp with control of buccal root torque and some
lingual crown movement). A harmonious position of the second molar is generally
observed within as short a time as 1 to 2 months (Fig 10d).17

CONCLUSION
It follows that the TPA is an excellent and useful tool in clinical practice. The strong 0.036-
inch palatal arch dominates over labially placed archwires. A TPA design with increased
length of wire compared with the standard Goshgarian-type, having one large anterior loop
and two smaller posterior loops (Fig 7b), shows clinically relevant advantages. It appears
to be an optimal appliance for several different treatment purposes, such as fast and
complete derotation of mesiolingually rotated maxillary first molars, adding buccal root
torque to the first molars, expansion of the maxillary arch, maintaining arch widths and
arch forms during treatment, supporting the posterior anchorage, improving vertical con-
trol, and correcting mesiodistal asymmetries. When the palatal arch is supplied with sol-
dered extension spurs, it can act as an ideal tool for tooth movements that are difficult, if
not impossible, to achieve with conventional labial archwires, including torque control, de-
impaction of palatally malposed canines, intrusion, and lingual movement of maxillary
second molars.

266
 REFERENCES
1. Bishara SE. An interview with Björn U. Zachrisson. World J Orthod 2002;3:370–374.
2. Gündüz E, Zachrisson BU, Hönigl KD, Crismani AG, Bantleon HP. An improved transpalatal bar design. Part I.
Comparison of moments and forces delivered by two bar designs for symmetrical molar derotation. Angle
Orthod 2003;73:239–243.
3. Gündüz E, Crismani AG, Bantleon HP, Hönigl KD, Zachrisson BU. An improved transpalatal bar design. Part
II. Clinical upper molar derotation—case report. Angle Orthod 2003;73:244–248.
4. DeBerardinis M, Stretesky T, Sinha P, Nanda RS. Evaluation of the vertical holding appliance in treatment of
high-angle patients. Am J Orthod Dentofacial Orthop 2000;117:700–705.
5. Dahlquist A, Gebauer U, Ingervall B. The effect of a transpalatal arch for the correction of first molar rota-
tion. Eur J Orthod 1996;18:257–267.
6. Wise JB, Magness WB, Powers JM. Maxillary molar vertical control with the use of transpalatal arches. Am J
Orthod Dentofacial Orthop 1994;106:403–408.
7. Stoller AE. The normal position of the maxillary first permanent molar. Am J Orthod 1954;40:259–271.
8. Andrews LF. The six keys to normal occlusion. Am J Orthod 1972;62:296–309.
9. Ten Hoeve A. Palatal bar and lip bumper in nonextraction treatment. J Clin Orthod 1985;19:272–291.
10. Ricketts RM. Occlusion—the medium of dentistry. J Prosthet Dent 1969;21:39–60.
11. Liu D, Melsen B. Reappraisal of Class II molar relationships diagnosed from the lingual aspect. Eur J Orthod
2001;23:457.
12. Fotis V, Melsen B, Williams S, Droschl H. Vertical control as an important ingredient in the treatment of
severe sagittal discrepancies. Am J Orthod 1984;86:224–232.
13. Hata M. Effect on the dentofacial complex of Macaca irus of functional tongue forces imparted on a palatal
bar—tongue forces imparted on palatal bar. J Osaka Dent Univ 1993;27:51–66.
14. Yamawaki H, Kawamoto T. Effect of palatal bar on maxillary molars during swallowing. Shika Igaku (J Osaka
Odontol Soc) 1996;59:53–63.
15. Chiba Y, Motoyoshi M, Namura S. Tongue pressure on loop of transpalatal arch during deglutition. Am J
Orthod Dentofacial Orthop 2003;123:29–34.
16. Sinclair PM, Little RM. Dentofacial maturation of untreated normals. Am J Orthod 1985;88:146–156.
17. Kucher G, Weiland FJ. Goal-oriented positioning of maxillary second molars using the palatal intrusion tech-
nique. Am J Orthod Dentofacial Orthop 1996;110:466–468.

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