differential straight arch technique

2. Contents
• Introduction
• Historical perspective
• Creation of the Tip-edge bracket
• Dynamics
• Tip-edge Plus Bracket
• Differential tooth movement
• Auxiliaries
• Bonding & setting up
• Treatment stages & sequence

3. • Stage I
• Stage II
• Stage III
• Finishing
• Conclusion
• References

4. Introduction
• Dr. Peter Kesling in 1986
• Was first introduced at the Kesling-Rocke
Orthodontic Centre, Westville, Indiana
• A differential tooth movement within an
edgewise based bracket system
• It combines an initial degree of tooth
tipping prior to ‘edgewise’ precision
finishing

5. Historical perspective
• Dr. Edward Angle in 1925
• Invented the ‘Edgewise’ bracket
• Provides the neatest way of achieving
3-dimensional root control
• His bracket was best suited to his non-extraction’
treatment doctrine

6. • Postwar period, several orthodontists reintroduced the
concept of extractions
• Dr. Raymond Begg developed a different bracket
system, which was a modification of Angle’s earlier
‘Ribbon-Arch’ bracket

7. • It was designed to overcome the prime disadvantages in
all edgewise systems
ie: every tooth is subject to mesio-distal bodily control from
the moment of arch-wire engagement, thus increasing
resistance to retraction
• The Begg technique, allowed teeth to tip freely during
initial stages of tooth translation.

8. • Although he was able to show cases treated with greater
speed and the use of ultralight forces, the Begg’s
Appliance, had inherent problems
 Root recovery was less than reliable
 Accurate molar control & buccal segment torque were
denied by the inability to use rectangular archwires
• In retrospect,
He stimulated thinking towards lighter forces, shorter
treatment times and the potential of differential tooth
movement

9. • The most notable innovation in bracket design came
with the advent of the straight –wire bracket system
pioneered by Dr.Lawrence Andrews in late 1970s.
• This was the direct development of edgewise design,
and introduced the concept of preadjusted appliance

10. Creation of the Tip-Edge
• The straight-wire system imposes many limitations
1. Moving teeth apex first generates maximum anchorage
resistance
2. Control of third order torque is primitive,
i.e torque transmitted by an active rectangular archwire
provokes an unwanted reciprocal torque reaction in
adjacent teeth
3. Torque prescription written-in each bracket may not be
achieved in clinical practice due to 10 deg of torque slop

11. • Thus he modified a single straight-wire bracket to create
the Tip-Edge
• The Rx-1 bracket

12. • removal of diagonally opposed corners from the
conventional edgewise slot allowing differential ooth
movement
• Thus each bracket is enabled to tip in a predetermined
direction

13. Features of Tip-edge Rx-1 bracket
• Conventional tie-wings for
elastomeric ligature
• Bracket identification
small circular markers on
disto-gingival tie wing for
maxillary anteriors
• triangular for mandibular

14. • Vertical slot lingual to main slot
• dimension of vertical auxiliary slot is 0.020 inches
square.
• with a rounded ‘funnel shaped’ entry to facilitate insertion

15. • The propeller slot
• Due to the lateral extensions
• Preserves rotational control
throughout he range of tip
• Not compromising on esthetics
as it is concealed beneath the
archwire

16. • Tip limiting surfaces- cut out
surfaces
• Finishing surfaces –Intact
surfaces
• Central ridge- meeting point of
T & F
• Opposing CRs provide vertical
control; also the point where
torque is imparted in final
rectangular wire phase

17. • tip-limiting surfaces are angled 25deg to horizontal on
canines, 20deg on other teeth
• Preadjusted finishing prescription (closest to Roth)

19. A DYNAMIC SLOT
• vertical dimension of archwire slot increases as tooth tips
during initial translation
• M-D of the Tip-limiting > M-D of Finishing

20. Molar tubes
• Double buccal tubes
1. Rectangular tube; .022*.028 inch
2. Gingivally placed round tube
• Rectangular tube: “EASY-OUT”
design
• Posterior inner lumen slightly flared
towards occlusal

21. Tip-Edge Plus
• Uprighting springs were required
to upright and torque teeth during
stage three, the final stage, of
Tip-Edge treatment.
• These springs could be
uncomfortable as well as
unsightly and were sometimes
lost or removed by patients

22. • features a “deep tunnel” through which either a .012” or
.014” nickel titanium wire is threaded at the beginning of
stage three
• not only uprights but also torques the teeth

24. • Positioning a root apex towards the direction of pull will
generate resistance to tooth movement in response to
that force
• It was for this reason that Charles Tweed developed the
concept of anchorage preparation:
 Moved apices mesially in the mandibular buccal
segments to increase anchorage resistance to Class II
traction
Differential tooth movement

25. • A bracket designed for differential tooth movement will
not impart root-angulating forces when the archwire is
engaged
• The crown tips in the direction of desired tooth
movement, leaving the root apex to trail behind

26. Variable anchorage control
• Root torque is imparted by the placement of auxillary
springs
• Orthodontist now has the choice of which tooth to control
and when,introduce the concept of variable anchorage
control.

28. Vertical Reaction during Retraction
• Edgewise/straight-arch
• Roller-coaster effect
• Extrude labial; intrude
buccal
• Differential straight arch
• Apex left behind
• Vertical ‘round tripping’ of
anteriors is avoided

29. Bite opening
• Canine root angulations delay
bite opening in case of
edgewise and straight arch
• One way of overcoming this is
Segmental Arch approach
• In Tip-edge; overbite reduction
can take place irrespective of
canine angulation

30. Light forces
• It is fundamental to differential tooth movement that all
forces should be light .
• for example ,50 grams of intermaxillary elastic force
,bilaterally , will be quite sufficient for the reduction of
large overjet
• When periodontal response will theoretically be uniform
down the length root, tipping a tooth will induce more
root movement towards the gingival,
• Force diminishes towards the apex ,which may even
show slight reverse movement.
• the forces are therefore less evenly dissipated along the
root.

31. Root uprighting
• Vertical archwire
deflection in
conventional bracket
• Uprighting teeth with light
auxiliary springs causes
no vertical deflection of a
heavy passive archwire

32. Auxiliaries
• Many are Begg derived.
• Mainly:
1. Side-Winder
2. Power Pin
3. Rotating Spring

33. The Side-Winder
• Everyday “Workhorse”
• Generates mesio-distal root movement
• Produces torque correction when used in conjunction
with rectangular wires
• Made of 0.014’ high tensile SS
Torque correction
Tip correction

34. • The coils of the Side Winder are concentric with the point
of second order rotation of the bracket
• More esthetic and Easier for the maintenance of Oral
Hygiene
• Adds to the labial profile of the bracket

35. • Comes in clockwise and counter-clockwise formats
• Selection is according to the direction of the second
order correction required

36. • The ‘Invisible’ Side Winder:
 The long tails of the spring
were deleted
• Has several functional advantages-
 Esthetics are improved
 Retained in position by elastomeric
modules in addition to spring
pressure
 Spring arm has a wider range of
activation

37. • Must always be inserted from the occlusal and never
gingivally
• The spring arm points in the direction towards which the
occlusal tip will rotate
• Should only be used with SS Arch wires, as NiTi wires
are insuffciently stiff to resis vertical deflections
• Must only be used in conjunction with elastomeric
ligatures as the steel ligature will resis the action of the
spring

38. Power Pin
• Traction hook that can be fitted into the
vertical slot
• Made of soft stainless steel
• Inserted from the gingival
• Retained by bending the occlusally
projecting tail 90 deg
• Does not interfere with arch checks

39. • Head of the pin should be fitted to incline
away from the gingival margin
• Commonly used as hooks for seating
elastics in final treatment visits
• Occasionally useful when a single tooth
requires retraction as it reduces the risk of
rotation

40. Rotating spring
• .014inch SS
• Useful in rotations that recur in
treatment
• Ability to realign the rotation
without delay by stepping down to
a lighter wire

41. •Placement & Activation

42. Bonding & setting up
• Mid crown portion is
recommended
• Vertical axis of bracket parallel to
the long axis of the tooth
• Must be at the mid-point of the
tooth mesio-distally
• Height must be at the vertical mid-
point of the fully erupted CC

44. Disadvantage of the jig

45. Premolar brackets
90deg angulation

46. Selection of PM brackets for different
extraction patterns
First PM ext Second PM ext
Non-ext/ First Molar

47. Molar bands
• Use of bonded first molar tubes is contraindicated
• Rectangular buccal tube at mid-crown height
• Mandibular arch-tubes parallel to occlusal cusp
• Maxillary arch-seating the band fractionally higher
toward the distal may be helpful in obtaining final seating
of the distobuccal cusp
• 2nd molars: banded in Stage III -conventional .022×.028
inch rectangular tube

48. Treatment stages
• Repositioning of crowns, followed by root
uprighting
• Stage I
Anterior segment: alignment, space closure,
A-P, Vertical correction i.e overjet, overbite
0.016” S.S
NiTi ‘under arches’ frequently employed
6-9 months

49. • Stage II
• Residual spaces
• 3-4 months, more in Ist molar extraction
• Midlines matching
• Derotate molars
• 0.020” – free sliding,/ 0.022”- protraction,
crossbites

50. • Stage III
– Root Uprighting phase
– Sidewinders for torquing
– .0215 x 0.028”S.S
– Virtually maintenance free

52. Objectives
1. Alignment of upper and lower anterior segments
2. Closure of anterior spaces
3. Correction of increased overjet or reverse overjet
4. Correction of increased overbite or anterior open bite
5. Work toward buccal segment crossbite correction

53. Anchorage mode
• Tip-Edge appliance has the capability of combining
advantages of both Begg and Straight wire concepts
• Variable anchorage with Class II traction was
demonstrated by Dr. Begg
• Works effectively in Class II- difficult deep bites, (elastics
preferred over headgear)
• Side effects eg clockwise rotation of occlusal plane,
opening of mandibular angle, & elongation of upper
incisors avoided by use of light forces

54. • Class I & Class III without deep bites:
-horizontal mechanics are sufficient.
• In case of Class II with high mandibular plane angle,
avoidance of any potentially extrusive mechanics is
necessary.
• In such situations, intrusive forces derived using head
gear may be given

55. Setting up stage I

56. • Malocclusion features:
1. Class II molar relation
2. Increased overjet & over bite
3. Lower anterior crowding
• First PMs extracted

57. The base arch wire
Arch form
•Horse shoe shape arch form
is not appropriate
•As the anchorage bend
requires a straight posterior
leg
• .016 round high tensile
wire

58. Cuspid circles
•The anterior curvature is
interrupted by cuspid circles
•Postion of cuspid circle
In crowding: immediately
mesial to canine bracket
In spacing: further
mesially

59. Arch Expansion
•When using Anchor bends &
classII Elastics
•Expansion of 5 on either side
measured across molars

60. Pre-formed archwires
• .016 inch BOW-FLEX arch
wire
• Inter circle distance
measured between the
mesial surfaces of canine
brackets

61. Anchorage bend
• 2mm in front of molar
tube
• Enhance anchorage &
boost Vertical control
• Intrusive force 2ounces/
5ograms in upper
• Less in lower
• Must be used in round
molar tubes

62. Auxiliary arch
• Cut from anterior curvature of
Round .014 inch Niti
• To align anterior instanding teeth
• Extend 3mm distal to canine
bracket
• Distal ends turned 90 degrees to
the lingual

63. Fitting of the arches
•Auxiliary arch first, ligated to the instanding teeth
•Followed by the main arch on molar tube of one
side only, same side canine is ligated
•Followed by the other side
•Finally remaining incisors are ligated

64. Cuspid tie
• Wrong tie: elastic ligature lies beneath the
archwire
• Correct tie:
1. Ligature labial to the archwire mesially
2. Swiss twist

65. • Elastic ligature slid along the wire into the cuspid circle
• Lies loose till other brackets are ligated
• Lastly, the cuspid tie is engaged around the bracket with
mosquito forceps

66. Anterior spacing:
•E-Links are employed

67. Distal ends of arch wire
2mm should be left distally
to lower molar tubes to
accept the Class II elastics
Must be bent 30 deg
lingual
DO NOT Cinch gingivally:
Will drag the arch wire
distally and cause
retroclination of the
incisors

68. Inter maxillary elastics
•Force: 2 ounces/side
(50 gms)
•No unwanted side
effects.
•Use distal end of the
wire and not the molar
hooks
•If more- overcome
intrusive effect of the
upper anchor bends
•Thus elongate incisors

69. Straight shooter

70. Instructions for intermaxillary elastics:
• Power source and not an Add-on
• Big difference in progress resulting from 100% wear as
opposed to 90% wear
• 24hrs/day
• Removed only while brushing
• Changed nightly

72. Stage I checks:

73. Routine adjustments- 6 weeks
• Measure the overjet:
reduction 3-4mm/visit
• Failure due to partial elastic wear,
distal end of wire: may be protruding, must be shortened
• Observe the overbite:
• Failure due to partial elastic wear
Or damage to anchor bend.
• Molar widths
• Lingual rolling. (anchor bends too strong)

74. • Check the cuspid circles
Generally only necessary during initial visits
May need rolling mesially in spacing
Rolling distally in case of crowding
• Sitting of anchor bends: 2-3mm in front of molar tubes
• Distal arch ends:
May lengthen and require trimming
• Distortion of the archwire
Anchor bends o be reinstated
Patient cautioned against biting hard substances
• Reassess the elastic tension

75. Power Tipping
Danger of proclining lower incisors- anterior crowding -less
Over bite reduction in an already proclined lower incisor segment

76. Power Tipping
No loss of anchorage
In stage I arch wire
Need not wait until incisor alignment

77. Power Tipping
4 months later45º activation
Mesial root movement- minimal on
radiograph
The principle of moving the crown by the root force is unique to tip edge

78. References:
• Tip edge Orthodontics: Richard Parkhouse
• Peter Kesling: Dynamics of Tip-Edge bracket: AJO-DO
1989;96:16-28
• Kesling PC, Rocke RT, Kesling CK. Treatment with Tip-
edge brackets and differential tooth movement. AJO-DO
1991;99:387-402
• Kesling CK. The Tip-edge concept:eliminating
unnecessary anchorage strain. JCO 1992;26: 165-17

79. Stage II

80. Objectives of Stage II
• Closure of residual spacing.
-According to operator’s choice- retraction / protraction
• Correction of centre lines
• Derotation of first molars
• Leveling of first molars.
• Continuing crossbite correction
• Maintenance of stage I correction

81. Timing for Stage II
• Should begin synchronously in both arches.
• As soon as Stage I objectives are met i.e
Enamel to enamel contact
• Similar to straight wire practice with the advantage of
choice of retraction or protraction
• Inclusion of premolars prior to start of stage II.

82. Aligning the premolars:
• In case of increased overbite cases, PMs will be require
to be picked up & aligned Pre-Stage II
• Selection of brackets as per extraction pattern

83. • Remove .016 ss wire
• Bond the premolars
• Replace the anchor bends with vertical bite sweeps
 Reverse curve of Spee in the lower arch
 Increased curve of Spee or rocking horse curve in upper
• Re-insert wires into Rectangular
Molar Tubes
• Vertical bite sweep
Pre-stage II visit

84. Malpositioned Premolars
• Using elastic thread for
lingually displaced PMs
• Using E-chains or E-links
for rotated PMs

85. • For PMs which are both
lingually displaced &
rotated
• Ni-Ti ‘under-arch’
• Sectional if problem is
unilateral
• ‘piggy-back’ for full
auxiliary arch
• Further option: Lingual
attachments
• At the following visit,
should be easy to engage
.020 inch SS to begin
Stage II

86. • Round molar tubes- only in stage I
• On bonding of premolars - use rectangular tubes
• All subsequent wires whether, round or rectangular –
rectangular tubes should be used.
• No anchor/ bite opening bends to be used adjacent to
bonded premolars or in rectangular tubes
Molar tube usage

87. Stage II arch wires
• 0.020” high tensile SS preferred
• Intermediate to Flexible .016 and Rigid .022* .028
• Stiffer 0.022” SS can be employed in:
 maxillary arch- crossbite cases - buccal expansion
required
 Mandibular arch- 1st M ext-
better labiolingual control of 2nd molars and resistance to
mesial tipping

88. Space closure
• Buccal segment spacing can be closed by applying C-
links from Cuspid circles to Molar hooks
• Here, at this stage, the operator is given option of
retraction or protraction
• By adding the Side-winder Brakes

89. Applying the brakes
•Significantly increases
anterior anchorage, hence
resistance to retraction
•Usually used bilaterally
•More commonly in
•Lower arch - Class II
•Upper arch - Class III

90. Centerline correction
• Midline discrepancies are most easily corrected when
there is still space available
• If not coincident- it suggests Disparity in buccal segment
occlusion

91. •Scenario 1
Centerline deviated to the most crowded side
•May resolve without intervention, when residual
space is closed by retraction

92. •Scenario 2
Midlines matching with residual space
•defensive braked applied to left canine
•space closed by protraction of buccal segment

93. •Scenario 3
Active correction of midline

94. • Should be done at end of Stage II when all spaces are
closed
• Takes about 3 weeks
• This step must not be omitted
• Slight amount of mesial rotation will cause difficulty in
fitting the rectangular wires with .028 lateral dimension
Derotation of first molars

95. • To prevent space reopening, the distal end of archwire is
annealed and turned gingivally.

96. Levelling of first molars
• To correct the distal
crown tipping due to
anchor bend
• Anti-tip bend < 10degree

97. Continuing crossbite correction
• Buccal expansion- more effective in stage II
• 0.022” wire in maxillary arch may be required

98. Stage II checks: 6 – 8 week
intervals
• Observe space closure:
• replace E links if required
• Caused by premature toe-ins
• The distal archwire ends.
– Trimmed to 2mm of distal projection, turned
lingual
– Anneal & Bend back gingivally if all spaces
closed
• Check molar widths
• Labial segment position and inclination-
depending on retraction/protraction

99. • Attention to center lines
 Selective brakes
 Failure will result in occlusal discrepancy
• Derotation of first molars
 Essenial once space has closed
 1mm buccal offset & 10deg lingual toe-in
• ‘Un-tip” the first molars
 For seating the distobuccal cusps
• Avoid over compression
 Contact point pressure will retard or halt correction of
torque & tip in Stage III
• Check the interarch relationship-
 Patient wearing elastics/headgear to maintain
stage I correction?

100. Stage III

101. Objectives
• Correction of torque and tip angles for each tooth
individually
• Attainment of optimum facial profile compatible with
stability
• Maintenance of Class I occlusion
• Final detailing

102. Conventional torquing
• Fixed vertical slot dimension
• Active torque- rectangular cross-section archwire
• Torque force imparted depends on:
 Torque discrepancy b/w wire & bracket
 Elastic property of wire
 Deg to which the wire fills the slot
• Conflicting requirements?
 Ni-Ti arch wire or SS
 Arch wire size- .019* .025
• Will result in 10deg of torque slop

103. How does Tip-edge torque
Intact upper & lower FS are
offset
‘Torque escape’- actively torqued
rect wire –reopen the vertical
slot dimension, second order
root movement than torque

104. How does Tip-edge torque?
• Vertical slot opens up to a
possible .028 inch
• Therefore, an .022* .028
inch SS wire can be
easily fitted
• No torque will be
imparted a this point
except at the molars

106. Tip and torque-
selflimiting.
Overcorrection of tip
by 1deg as wire is
.0215 in .022 slot
zero torque
discrepancy

107. Points to note
• Sidewinder always oriented to untip the tooth not torque
• Two-point contact- curved path of root to finished position
• Inadequate tip- inadequate torque and vice versa
• Force values decline – 60g to 20g at the apex
• Force values can be restored by Hyper activation- incisors
• Not less than .0215 x .028 cross section– narrowing the
torquing platform- reduces effectiveness of spring

108. Anchorage considerations
A cephalometric
radiograph to be taken
prior to onset of Stage III
Contiguous anchorage
Elastic or headgear use

109. Stage III archwires
• Only one size
• .021* .028 inch ‘Shiny
Bright’ SS
• Plain or pre-torqued
• Archwidth expanded by
2mm per side across 1st
M
• 3mm protruding distal to
molar tube
• 5deg toe-in placed opp
mesial molar contacts

110. • Traction hooks
• Mid way b/w lateral incisor
& canine bracket
• Always point gingivally

111. • Preparation of arch ends
• Essential to cinch the
ends gingivally to
prevent unwanted
spacing
• Distal ends ground out
from lingual to half
original width
• Annealing with flame or
grinding wheel

112. Stage III- Fitting the archwires
• Only molars-torque
from beginning
Testing the molar torque:
height discrepancy of free end
on opp side
Torque on molars- heavy

113. •A small amount of anterior archwire intrusion is
required to retain a previously deepened bite
throughout stage III
•Palatal root torque can be added to upper incisors by
lifting the tails of the archwire

114. Cinch backs
30°
• Required in all cases
• Must be placed and
tested before fitting the
springs and modules
• 0.5 to 1mm of free space
needed in each arch
• If present:

115. • If space not present
anywhere in the arch or if
presence of overlapping
contacts
• Whichever cinch back
used; must not exceed
30deg- difficult to remove

116. Sidewinders and elastomeric
modules

117. Degree of activation
•Canines and premolars- tip correction- about 45
deg
•For incisors requiring torque control- full
activation
•Excess activation- loss of anchorage

118. Removal of archwires
•If ends are annealed and trimmed: no difficulty to be
encountered
•Cinch back straightened with Howe plier
•Grasp wire between molar and PM
•Rotate forward
•“walk” the wire out mesially

119. Stage III checks
1. Progress of the tip and the torque

120. Stage III checks:
• 2. Available space in
the arch:

121. 3. unwanted space
4. Condition of side-
winders
5. Activation of side-
winders
6. Interarch relationship
7. The vertical
relationship

122. How to admit extra space?
‘Hyper activation’ of side-winders

123. Causes of inadequate torque
1. Incorrect bracket
2. Misangled bracket
3. Incorrect archwire
4. Incorrect bonding position
5. Incomplete bracket engagement
6. Wire ligatures
7. Tight contact points
8. Slack side-winders
9. Incorrect torque in archwire

124. Precision finishing:
• Self-limited precision finish
• Previously unnoticed errors come to light eg incorrect
bracket positioning
• These can be corrected fairly easily in Stage III if not
Over-Uprighted
• Only occlusal seating required
• Second molars to be assessed for inclusion

125. Picking up second molars
• Seldom banded until late
in the treatment
• Since overbites correct
with light intrusive forces
• Including initially-
Obstructive – unwanted
friction
• .022 x .028” molar tubes
• Preliminary alignment-
late stage III-Dr. Tom
Rocke
Straight .016” SS
sectionals to pick up
second molars in Stage III

126. Occlusal seating
For final seating- vertical elastics can be employed to
molar hooks and power pins
3 weeks
Braided rectangular arches
Titanium-niobium archwires

127. Sectioning the main archwire
may be cut distal to canine
May Extrude buccal cusps, leaving palatal cusps
unseated

128. Positioners:
•No finishing wires
•Pre-Fit Positioners
•Diff sizes- Xn / non Xn
•Individual tooth size
discrepancy

129. The non-compliant patient

130. Outrigger appliance

132. Conclusion
To conclude with aircraft analogy, wheels are not
required during flight. They fold away to make the
journey easier but become vitally necessary when
landing.
If taking up finishing angulations early in treatment
makes the journey more difficult, the philosophy
behind Tip-Edge makes obvious sense.
Finishing angulations do not become necessary until
the Finish of treatment.
Although it make require a steep new learning curve to
depart from convention, the results surely expand
the horizons of fixed appliance capability

133. Tip-Edge Today

136. References:
• Tip edge Orthodontics: Richard Parkhouse
• Peter Kesling: Dynamics of Tip-Edge bracket: AJO-DO
1989;96:16-28
• Kesling PC, Rocke RT, Kesling CK. Treatment with Tip-
edge brackets and differential tooth movement. AJO-DO
1991;99:387-402
• Kesling CK. The Tip-edge concept:eliminating
unnecessary anchorage strain. JCO 1992;26: 165-17