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Tip edge appliance

differential straight arch technique

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Tip edge appliance

  1. 1. 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
  2. 2. • Stage I • Stage II • Stage III • Finishing • Conclusion • References
  3. 3. 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
  4. 4. 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
  5. 5. • 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
  6. 6. • 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.
  7. 7. • 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
  8. 8. • 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
  9. 9. 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
  10. 10. • Thus he modified a single straight-wire bracket to create the Tip-Edge • The Rx-1 bracket
  11. 11. • 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
  12. 12. 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
  13. 13. • 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
  14. 14. • 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
  15. 15. • 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
  16. 16. • tip-limiting surfaces are angled 25deg to horizontal on canines, 20deg on other teeth • Preadjusted finishing prescription (closest to Roth)
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. • 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
  21. 21. • 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
  22. 22. • 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
  23. 23. 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.
  24. 24. 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
  25. 25. 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
  26. 26. 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.
  27. 27. Root uprighting • Vertical archwire deflection in conventional bracket • Uprighting teeth with light auxiliary springs causes no vertical deflection of a heavy passive archwire
  28. 28. Auxiliaries • Many are Begg derived. • Mainly: 1. Side-Winder 2. Power Pin 3. Rotating Spring
  29. 29. 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
  30. 30. • 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
  31. 31. • Comes in clockwise and counter-clockwise formats • Selection is according to the direction of the second order correction required
  32. 32. • 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
  33. 33. • 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
  34. 34. 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
  35. 35. • 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
  36. 36. 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
  37. 37. •Placement & Activation
  38. 38. 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
  39. 39. Disadvantage of the jig
  40. 40. Premolar brackets 90deg angulation
  41. 41. Selection of PM brackets for different extraction patterns First PM ext Second PM ext Non-ext/ First Molar
  42. 42. 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
  43. 43. 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
  44. 44. • Stage II • Residual spaces • 3-4 months, more in Ist molar extraction • Midlines matching • Derotate molars • 0.020” – free sliding,/ 0.022”- protraction, crossbites
  45. 45. • Stage III – Root Uprighting phase – Sidewinders for torquing – .0215 x 0.028”S.S – Virtually maintenance free
  46. 46. 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
  47. 47. 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
  48. 48. • 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
  49. 49. Setting up stage I
  50. 50. • Malocclusion features: 1. Class II molar relation 2. Increased overjet & over bite 3. Lower anterior crowding • First PMs extracted
  51. 51. 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
  52. 52. 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
  53. 53. Arch Expansion •When using Anchor bends & classII Elastics •Expansion of 5 on either side measured across molars
  54. 54. Pre-formed archwires • .016 inch BOW-FLEX arch wire • Inter circle distance measured between the mesial surfaces of canine brackets
  55. 55. 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
  56. 56. 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
  57. 57. 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
  58. 58. Cuspid tie • Wrong tie: elastic ligature lies beneath the archwire • Correct tie: 1. Ligature labial to the archwire mesially 2. Swiss twist
  59. 59. • 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
  60. 60. Anterior spacing: •E-Links are employed
  61. 61. 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
  62. 62. 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
  63. 63. Straight shooter
  64. 64. 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
  65. 65. Stage I checks:
  66. 66. 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)
  67. 67. • 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
  68. 68. Power Tipping Danger of proclining lower incisors- anterior crowding -less Over bite reduction in an already proclined lower incisor segment
  69. 69. Power Tipping No loss of anchorage In stage I arch wire Need not wait until incisor alignment
  70. 70. 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
  71. 71. 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
  72. 72. Stage II
  73. 73. 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
  74. 74. 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.
  75. 75. 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
  76. 76. • 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
  77. 77. Malpositioned Premolars • Using elastic thread for lingually displaced PMs • Using E-chains or E-links for rotated PMs
  78. 78. • 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
  79. 79. • 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
  80. 80. 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
  81. 81. 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
  82. 82. 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
  83. 83. Centerline correction • Midline discrepancies are most easily corrected when there is still space available • If not coincident- it suggests Disparity in buccal segment occlusion
  84. 84. •Scenario 1 Centerline deviated to the most crowded side •May resolve without intervention, when residual space is closed by retraction
  85. 85. •Scenario 2 Midlines matching with residual space •defensive braked applied to left canine •space closed by protraction of buccal segment
  86. 86. •Scenario 3 Active correction of midline
  87. 87. • 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
  88. 88. • To prevent space reopening, the distal end of archwire is annealed and turned gingivally.
  89. 89. Levelling of first molars • To correct the distal crown tipping due to anchor bend • Anti-tip bend < 10degree
  90. 90. Continuing crossbite correction • Buccal expansion- more effective in stage II • 0.022” wire in maxillary arch may be required
  91. 91. 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
  92. 92. • 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?
  93. 93. Stage III
  94. 94. 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
  95. 95. 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
  96. 96. 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
  97. 97. 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
  98. 98. Tip and torque- selflimiting. Overcorrection of tip by 1deg as wire is .0215 in .022 slot zero torque discrepancy
  99. 99. 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
  100. 100. Anchorage considerations A cephalometric radiograph to be taken prior to onset of Stage III Contiguous anchorage Elastic or headgear use
  101. 101. 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
  102. 102. • Traction hooks • Mid way b/w lateral incisor & canine bracket • Always point gingivally
  103. 103. • 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
  104. 104. 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
  105. 105. •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
  106. 106. 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:
  107. 107. • 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
  108. 108. Sidewinders and elastomeric modules
  109. 109. Degree of activation •Canines and premolars- tip correction- about 45 deg •For incisors requiring torque control- full activation •Excess activation- loss of anchorage
  110. 110. 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
  111. 111. Stage III checks 1. Progress of the tip and the torque
  112. 112. Stage III checks: • 2. Available space in the arch:
  113. 113. 3. unwanted space 4. Condition of side- winders 5. Activation of side- winders 6. Interarch relationship 7. The vertical relationship
  114. 114. How to admit extra space? ‘Hyper activation’ of side-winders
  115. 115. 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
  116. 116. 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
  117. 117. 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
  118. 118. Occlusal seating For final seating- vertical elastics can be employed to molar hooks and power pins 3 weeks Braided rectangular arches Titanium-niobium archwires
  119. 119. Sectioning the main archwire may be cut distal to canine May Extrude buccal cusps, leaving palatal cusps unseated
  120. 120. Positioners: •No finishing wires •Pre-Fit Positioners •Diff sizes- Xn / non Xn •Individual tooth size discrepancy
  121. 121. The non-compliant patient
  122. 122. Outrigger appliance
  123. 123. 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
  124. 124. Tip-Edge Today
  125. 125. 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