Modern Edgewise Mechanics and The Segmented Arch Technique Dr. Charles J. Burstone with Dr. Edsard van Steenbergen Dr. Kevin J. Hanley Department of Orthodontics University of Connecticut School of Dental Medicine Farmington, Connecticut 06030-1725ACKNOWLEDGMENTS The authors would like to recognize the many contributions of the faculty, residents and researchers at the University of Connecticut and Indiana University in the preparation of this book. Part of the introductory sections in chapter 1 were written by Drs. Ken Yoshikawa and Bruce Gottlieb. Dr. Phil Pasquale suggested the cuspid-to-cuspid stabilizing segment that is described for cuspid retraction ‘New data and concepts are presented in the use of T-Springs in extraction patients, which is based on research from the Biomechanics Laboratory in the Department of Orthodontics at the University of Connecticut. The pioneering work of Dr. Andrew Kuhlberg established the role of eccentricity of loop placement and the standard shape for clinical goals. This was followed by Dr Kwangchul Choy and Mr. Felix Mathieu, who researched in detail the relation of loop shape, eccentricity, and interbracket distance on the force system. The tables in appendix A and their nization is based on their work. The data for short "T"-Loops was obtained by Dr. Ali Ghatr We would also like t thank Mrs. Kim Wolfe for her significant contribution in preparing typing the manuscript. Mrs. Diana Mikulak was invaluable in organizing the text and integrating the manuscript into a meaningful format. In close collaboration, Dr. Kwangchul Choy and Mr. Felix Mathieu prepared the new tables, graphs, and were significant contributors to the conceptual development of the textTABLE OF CONTENTS CHAPTER 1 FORCE SYSTEMS AND THE APPLIANCE ‘THE FORCE SYSTEM... Moment to Force Ratios. Force Constancy Wire Cross-Section Wire Length Wire Material Wire Configuration Force and Moment Magnitude Anchorage Control Frictionless Force Application RATIONALE OF THE SEGMENTED ARCH... Consolidation of Teeth into Units Varying Cross-Section of Arch Wire Interattachment Distance and Force Distribution Around At Prefabrication and Precalibration. Clinical Efficiency Summary CHAPTER 2 ATTACHMENTS AND PLACEMENT .. ‘The Attachments Placement of Attachments, Second Order Level Second Order Angulation First Order Placement. CHAPTER 3 INITIAL TREATMENT PHASE - ANCHORAGE UNITS AND. ALIGNMENT... sess 23 THE POSTERIOR ANCHORAGE UNIT... rnnnnnnnnnee BB ‘The Buccal Stabilizing Segment B Precision Lingual Arches 2: Bracket Placement z Selection of Wire Cross Section Fabrication of the Upper Transpalatal Arch (TPA). cy Fabricating Upper and Lower Horseshoe Arches 28 INTRA-ARCH AND INTRA-SEGMENTAL ALIGNMENT. 29 CHAPTER 4 DEEP OVERBITE CORRECTION .. Principles of Anterior Intrusion Controlling Force Magnitude and Constancy Anterior Single Point Contact Point of Force Application Selective Intrusion, Control of the Reactive Units Avoiding Extrusive Mechanics Continuous Intrusion Arch. Three-Piece Intrusion Arch. Miscellaneous Methods of Intrusion 2 Posterior Extrusion 45CHAPTER 5 EN MASSE SPACE CLOSURE... Anchorage Classification EN MASSE ANTERIOR RETRACTION - POSTERIOR PROTRACTION (Group B Arches) eewe~ 52 Spring Preactivation. EN MASSE ANTERIOR RETRACTION (GROUP A ARCHES).. (Composite Retraction Spring Standard T-Spring with Posterior Spring Position EN MASSE POSTERIOR PROTRACTION (GROUP C ARCHES). Protraction Headgear Unequal Moments (M, > Ms) Equal Momemts (M, =Mg) and Imermaxillary Elastics CHAPTER 6 SEPARATE CANINE AND INCISOR RETRACTION. Separate Canine Retraction. Separate Canine Retraction with Cuspid-To-Cuspid Bypass (Stabilizing Segment) 69 Separate Incisor Retraction n CHAPTER 7 CANINE AND INCISOR ROOT MOVEMENT......... En Masse Root Movement Separate Canine Root Correction a4 Incisor Root Movement 86 APPENDIX REFERENCES........ —Table of Figures ee Figure 1. Position of force determines center of rotation 3 Figure 2. Burstone cuspid bracket with vertical tube. 4 Figure 3. Burstone maxillary first molar brackets. 4 Figure 4, Burstone mandibular first molar bracket. 4 Figure 5. Burstone precision lingual hinge cap bracket. 5 Figure 6, Tooth axes in three dimensions y Figure 7. 45° headfilm gives oriented view of buccal segments 19 Figure 8. Pa headfilm is useful to evaluate incisor axial inclinations and asymmetries 20 Figure 9. Buccal segment with welded or soldered tie back. 24 Figure 10. Crimped washer tie back on buccal segment Figure 11. Transpalatal arch: a) anterior insertion. B) posterior insertion 2 Figure 12, Maxillary lingual horseshoe Figure 13. Composite arches wires Figure 14. A) proclined incisor. B) incisor with normal axial inclination. C) retroclined incisor Figure 15. A) Force distal to center of resistance. B) Force through center of resistance. Figure 16. A straight wire moves roots mesially if placed in extruded central incisors. 37 Figure 17. An intrusion force on the incisors produces extrusion and lingual tipping of the molar. ......38 Figure 18. A straight wire through an angled cuspid bracket will erupt the incisors. 38 Figure 19. Continuous intrusion arch 40 Figure 20. A) passive 3-piece intrusion arch. B) activated intrusion spring a Figure 21. Cuspid intrusion. 44 Figure 22. Rotation of posterior teeth-as-a-unit eliminates excessive curve of spec. 45 Figure 23. Upper posterior parallel eruption with anterior bite plate and vertical elastics 46 igure 24. Parallel eruption of both upper and lower posterior teeth 41 Figure 25. Anterior bite plate and vertical elastics to correct anteriorly converging occlusal planes. .....47 Figure 26. Distances measured to determine activation of a T-loop 31 Figure 27. Asymmetric spring shape giving a moment greater than 8 moment 60 Figure 28. Angulation placed in spring prevents rotation of canine during retraction 66 Figure 29. Elastics with a TPA or lingual arch can narrow canines during retraction 66 Incisor bypass for separate canine retraction (labial view). 68 Incisor bypass maintains cuspid width and prevents rotation (occlusal view). Typical anti-rotation bends bent into incisor bypass wire With a unilaterally rotated canine, a symmetrical bypass produces unequal distal forces ‘Separate incisor retraction a) with bypass arch, b) with t-spring, 5. Helical spring for en masse root movement. ‘A smooth curvature will also produce equal and opposite couples 7. En masse root correction 9 Separate canine root movement with a continuous arch bypassing the canine. 81 Canine bypass with welded rectangular loop for root movement 82 Buccal segment with rectangular loop for canine root movement 82 Root spring for central incisorsCHAPTER 1 FORCE SYSTEMS AND THE APPLIANCECHAPTER 1 FORCE SYSTEMS AND THE APPLIANCE A clear definition of treatment goals is necessary in order to design an appliance system that will efficiently achieve the desired objectives, Once the treatment goals have been defined, an appliance system must be carefully designed to achieve the movements and positions of the teeth in three- dimensional space. Modem orthodontics requires that the spatial relationship of the dentition to the bony and soft tissue structures of the craniofacial complex be considered as well as alignment of the teeth within an arch and with respect to the opposing arch Regardless of the specific type of appliance system that is designed to achieve the desired treatment objectives, the following appliance design criteria should be considered 1. Force system 2. Ease of Use 3. Patient Comfort 4. Minimal Patient Cooperation Since the force system to achieve the desired tooth movement is fundamental in designing an appliance system, this topic is discussed separately under its own section. The other items listed above are discussed in conjunction with the rationale for the segmented arch concept and with the specific appliances that are described in detail later. ‘THE FORCE SYSTEM In order to achieve the desired tooth movements, the proper force system is a critical quirement, The following factors related to the force system are potentially under the control of the clinician 1, Moment to Force Ratio at the Attachment Constancy of Force and Moment 3. Magnitude of Force and Moment The desired tooth movement dictates the required force system. The design of the appliance determines the actual force system delivered to the tooth. By initially defining the relationship between the force system and the desired tooth movement, the orthodontic appliance can be specifically designed to deliver the appropriate force system Some of the basic concepts of tooth movement are reviewed in the following paragraphs to better understand the role of the moment to force ratio on tooth movement.One of the important concepts of tooth movement is that of center of resistance (Cj). It is defined as that point through which a pure force will produce only translation. For a single rooted tooth, this point is approximately 66% of the root length from the apex towards the alveolar crest; for a multirooted molar the Cu is near the furcation. Center of rotation (Ca), on the other hand, is defined as the point about which a tooth rotates. Depending on the force system applied, the center of rotation can vary. For example, incisor retraction can occur differently based on the location of the center of rotation: uncontrolled tipping about a point near the center of resistance, controlled tipping about the root apex, root movement with the center of rotation near the bracket, and translation where the center of rotation approaches infinity (Figure 1). Note that this description is discrete and that in reality tooth movement is on a continuum. Figure 1. Position of force determines center of rotation. A pure force applied to the labial surface of an incisor (at the bracket) will produce uncontrolled tippi with the crown moving lingually and the root apex labially. The point about which the tooth rotates is just below the center of resistance. In order to produce controlled tipping of the tooth about its root apex, a pure force must be applied more apically than the bracket near the cemento-enamel junction. For translation, no rotation of the tooth occurs; therefore, the center ofItis oted fora fined ation er of t the enter ooth wee out of, the of rotation would be at infinity by definition A force required to produce such movement must be located at the center of res tance approximately one-third the root length apical of the alveolar crest. Root movement by a single force can also be produced if the force passes through a point apical to the center of resistance. Notice that as the point of force application is moved apically, the center of rotation tends to vary considerably Moment to Force Ratios The problem we face as orthodontists is that we are restricted as to the point of force application due to the vestibular height and the patient's tolerance of appliances which irritate or interfere with the soft tissue. Therefore, in order to produce movement other than uncontrolled tipping by applyin force system only at the bracket, a single force alone is insufficient, a rotational tendency (a moment) must also be applied to the bracket. The proportion of the rotational tendency (moment) to the force applied at the bracket will determine the type of tooth movement produced. This is represented by the moment to force ratio (M/F) at the bracket. The center of rotation (which characterizes the type of tooth movement) is determined by this M/F parameter for a given tooth. For an average maxillary incisor, approximate values of the M/F are given below for different tooth movements. Table 1. Moment To Force Ratio At Bracket For Maxillary Central Incisors (Typical Values) Root Movement The moment to force ratio plays an important role in anchorage control. By varying the moment to force ratio applied to the anterior and posterior segments during space closure after bicuspid extractions, the amount of forward displacement of the posterior segments can be controlled This consideration will be discussed in greater detail in a subsequent section. Force Constancy If we accept the assumption that the most desirable type of tooth movement is produced by a relatively constant ‘ce within an optimal range, then we will want to design the active components ofan appliance such that they have desirable spring properties as follows: first, a low load-deflection rate of the spring appliance; and second, a frictionless force application system. Load-deflection rate refers to the amount of force produced for every unit of activation of an orthodontic wire or spring. The lower this rate, the more constant is the force as the tooth moves and the appliance is deactivated. In designing such a characteristic into the appliance, the appliance must have a sufficiently high elastic maximal strength such that the desired forces can be applied safely without permanent deformation. There are four major design parameters available to the clinician to vary the load-deflection rate: 1. Wire Cross-Si 2. Wire Length, Wire Material 4. Wire Cont Wire Cross-Section The load-deflection rate varies directly as the fourth power of the diameter of a round wire and as the third power of the depth of a rectangular wire. Therefore, reducing the cross-section of the wire can significantly reduce the load-deflection characteristics of an orthodontic appliance. The limiting factor in the reduction of the wire cross-section is the maximal elastic strength of the wire. The wire size must be such as to prevent permanent deformation during mastication. In designing those components of an appliance that are to be used for active movement (ie. anterior retraction spring is desirable to use wire cross-sections that are as small as possible without sacrificing the necessary freedom from permanent deformation. On the other hand, those parts of the appliance that are concerned with the preservation of anchorage require a relatively rigid wire with a large cross-section. The effect of a rigid wire attachment between anchorage teeth is to enhance the anchorage potential of these units by producing a more advantageous stress distribution in the periodontal structure to prevent the movement of the anchorage unit than if teeth were allowed to tip as individual units. Also, undesirable side-effects are minimized with the use of rigid wires in the anchor units, since there is less likelihood of disturbing the teeth immediately adjacent to the points of force application. Since tooth alignment problems may be radically different from one segment of the dental arch to another, it is useful to vary the shape and cross-sections of wire in an arch. By varying arch wirecross-sections, optimal wire properties can be utilized for the specific purposes at hand. One of the objectives of segmentation is to allow the utilization of the proper wire cross-sections for both tooth movement and tooth stabilization. I Wire Length | The wire length in a simple cantilever changes the load-deflection rate inversely as the third power. Therefore, small increases in length of wire can also dramatically reduce the load-deflection | rate. In continuous arch multibanded appliances, the wire length, to a great extent, is dictated by the interbracket distance between adjacent teeth, although some length can be added to the wire by using | loops By segmentin; the distances between points of force application (interattachment distance) are dramatically increased. The clinician is not limited by an arch wire which must go in sequence from ‘one bracket to the next on adjacent teeth For some types of tooth movement, the effective interattachment distance can be as great as 40 mm (je. an intrusive base arch with posterior attachments at the molar auxiliary tubes and an anterior attachment produced by a tie to the anterior segmental wire), The longer wire with a larger interattachment distance delivers a more constant force magnitude as well as a more constant force direction as the teeth move to the new desired positions Less angular change in force direction occurs if the interattachment distance is longer. Wire Material Newer materials are becoming available to the orthodontists in designing better appliances Stainless steel alloys are in common use today, having replaced the lower strength gold alloys many years ago. In order to improve the characteristics of stainless steel arch wire, multi-stranded wires with greater flexibility than solid wires (ie. reduced load-deflection rate) have been introduced. Currently alloys such as NiTi and beta titanium with a lower moduli of elasticity and high springback have radically changed appliance design. Wire Configuration In order to best utilize the effect that wire length has on load-deflection rate, the design of the wire configuration should be carefully considered. By placing more wire at regions where bending deflections are the greatest and regions where the bending moment is large, the load-deflection rate can be optimally reduced. This concept of wire configuration and loop design will be discussed in ‘greater detail in a later section.Force and Moment Magnitude The third parameter that must be considered with respect to the force system is the magnitude of the force and the moment. In addition to the obvious consideration of tissue damage, force and ‘moment magnitudes are important in anchorage control Since the control of the force system is critical in achieving the desired treatment goals, the accuracy in determining and maintaining force and moment levels become more than just academic. An appliance with a low load-deflection rate is important in accurately calibrating these levels. A small error in activation of a spring with a high load-deflection rate will result in a large error in the activation force. Using a high load-deflection rate spring of 500 g/mm as an example, ifa force level of 250 g is desired, the activation of the spring would be only 0.5 mm. This small amount of activation would be clinically difficult to achieve A 0.5 mm error in the activation would result in an error in the force level of +250 g, For a spring with a much lower load-deflection rate of approximately 30 g/mm, a 0.5 mm activation error would result in an error in force level of only +15 Anchorage Control As noted earlier, in controlling the displacement of teeth, the force magnitude is an important parameter. Traditionally, the stress levels on the anchorage unit have been reduced by distributing the force over more teeth, To achieve a more advantageous stress pattem in the periodontium of the anchorage unit, heavy rigid arch wire segments can be used to allow all the teeth in the anchorage unit to react uniformly. This stress pattern can be further enhanced by applying a moment which would cause the anchorage unit to translate instead of tip, By arefully monitoring the magnitude and the moment to force ratio of the force system, stress levels in the anchorage unit can be controlled and the use of an extraoral appliance which requires patient cooperation might be reduced Frictionless Force Application In order to achieve constant force and moment levels, sliding frictional forces must be climinated or reduced. An appliance system that requires sliding movements of the brackets over the arch wire may experience frictional forces that can impede the movement of the teeth. As an example,if'a cuspid is retracted along an arch wire, frictional forces will be created and the arch wire binds in the bracket. These frictional forces will alter the predictability of the desired forces on the teeth during this retraction process. RATIONALE OF THE SEGMENTED ARCH Consolidation of Teeth into Units The concept of the segmented arch technique has been developed in order to achieve the appliance design objectives that are dictated by the desired tooth movements and required force system. Conceptually segmentation allows the treatment to proceed by consolidation of teeth into units. For example, the buccal group of teeth which might consist of a second molar, a first molar and a second bicuspid would be consolidated into a buccal segment. Minor alignment within this segment (intrasegmental mechanics) is generally completed early in treatment to achieve proper intrasegmental tooth-to-tooth relationships. During intrasegmental mechanics, first molars can be stabilized across the arch with the use of a lingual or transpalatal arch wire; then the other teeth in this segment can be aligned with respect to these first molars. Since mechanically only a few teeth need to be considered for any segment, the alignment can be easily achieved by using properly designed segmented arch wires which will deliver the desired force system The anterior teeth are also consolidated. If alignment cannot be readily achieved without initially flaring due to crowding, the crowding is relieved by separate cuspid retraction to in the required space. In this manner, "round-tripping" of incisors can be minimized. Once teeth within segments are aligned, each is treated as one large multi-rooted tooth. At this stage, there are generally three arch segments: anterior, right buccal and left buccal segments, Just as a few teeth were consolidated into a segment, the s gments are now consolidated into a complete arch. The buccal segments are first consolidated by the use of a lingual or transpalatal arch wire to form a posterior anchorage unit. The posterior and anterior segments are next consolidated retraction in the case of bicuspid extraction cases. In align jeeth within a segment, loops should not be placed in the arch wires indiscriminantly to simply increase the flexibility (reduce the load-deflection rate). The loops should be designed to deliver the proper force system; it should be remembered that this concept of proper force system is basic in the design of any orthodontic appliance. Because the segmental arch wire is attached to only a few teeth the few loops in this arch wire can be readily designed to achieve the proper force system for 8the desired tooth movement. The subject of arch wire loop design is not a trivial one and will be dealt with in detail later Varying Cross-Section of Arch Wire ‘Segmentation allows the use of wires with different cross-sections at different locations in the same arch. In connecting teeth together as a single unit, rigid wires with high load-deflection rate are desired (ie. wires with a large cross-section). In designing active springs to deliver forces to achieve the desired tooth movement, wires which have low load-deflection characteristics are desired (ie. wires with smaller cross-sections or low modulii of elasticity), Interattachment Distance and Force Distribution Around Arch A segmented arch should not be confused with a sectional arch which simply contains portions of a continuous arch wire that are not joined in any way to form an integral system. The segmented arch technique allows the consolidation of teeth into the final arch position with the use of force systems which optimally distributes forces around the arch With segmentation, forces used during major intersegmental mechanics are applied at relatively large distances apart. For example, during space closure and consolidation of the posterior and anterior segments, forces are applied at the first molar attachments and the cuspid attachments, This large dimension allows the use of a long appliance with a low load-deflection rate The active and reactive forces occur between segments so that the forces can be distributed over many teeth. In the continuous arch wire, the active and reactive forces generally occur between two adjacent teeth and cannot be readily distributed to other teeth without introducing complex bends in the arch wire Side-effects of the forces can be more easily controlled when the forces are applied between segments, Segments, which generally consist of multiple teeth having multiple attachment points, multiple arch wires, and non-adjacent points of attachment, can be employed to minimize or eliminate undesirable side effects. Prefabrication and Precalibration Although segmentation of the arch is not necessarily a requirement for achieving proper force systems, segmentation does allow the use of specialized spring to be prefabricated and precalibrated to deliver the desired forces. The use of a precalibrated spring with known force system characteristics isimportant since the measurement of a moment is not always easily accomplished clinically. A prime example of such a spring is the one used for space closure after extractions; in which the force and moment values are important to achieve the desired tooth movement for preservation (or loss) of and will be discussed in detail later. Some other appliances which can be prefabricated readily and maintained in stock are base arch springs for intrusion ranspalatal arch wires, lower lingual arch wires and tip-back springs. By keeping | anchorage. Specialized retraction assemblies with differing force systems are commercially available, a supply of these prefabricated appliances in stock, chair time for the busy clinician can be reduced. a | nical Efficiency | For the clinician, there are other practice management benefits which are derived from the use of segmented arch technique. It is easier for most clinicians to construct an accurate segmental arch wire than it is to incorporate a complicated number of twists and bends into a complete continuous arch wire to accommodate bracket variations. Small arch wire segments can be easily read relative to the brackets and the specific adjustment can be made. Once intrasegmental mechanics are completed early in treatment, heavy (ie. 0.017" x 0.025” or larger) segments are placed passively; once in place, these arch wire segments need not be replaced during the remainder of active treatment. The need to constantly change arch wires as in the continuous arch technique is eliminated, thereby saving the clinician time and removing the problem of trying to reproduce identical wire configurations to maintain passivity Early visits may be longer because of the la number of arch wires placed at the start of active treatment in the se; nented arch technique as compared to that in the continuous arch wire concept. This initial time investment is more than compensated for by the reduction in the number of required wire replacements and enhanced ability to accurately fabricate and read an arch wire. | Summary In summary, the segmented arch appliance system provides some unique design advantages: 1. Segmentation offers the possibility of using multiple wire cross-sections and materials within the same arch. This permits a great deal of versatility in the selection of the proper wire for a given tooth movement for an optimal constant force. It also allows the selection in the same arch of more rigid wires with heavy cross-sections which are needed to control the anchor teeth.» Segmentation increases the distance between points of force application. The increased dimension lowers the load-deflection rate of the wire, minimizes directional changes as teeth move, and makes space available for the long activations that are needed in springs with low load-deflection rates. Unlike the continuous arch wire in which actions and reactions may occur between adjacent teeth, segmental principles can be used for a better distribution of forces around the arch to those teeth that are most able to withstand displacement. Reactive forces and moments may cancel themselves if they are properly distributed to the anchorage unit. ‘A segmented arch can be prefabricated so as to not only increase office efficiency but give greater accuracy to the orthodontist in force control. These prefabricated springs of various types can easily be calibrated, and convenient tables which give the force delivered for any given degree of millimeter of activation may be constructed With segmentation, all segments need not be routinely replaced as treatment progresses. Only those parts of the arch that need a different wire configuration need to be changed, and thereby duplication of wires is kept to a minimum.