CHAPTER XIV
TREATMENT MECHANICS
Jorge Aya/a
Many treatment schemes have been pro-
posed and described in a manner that leads the
orthodontist to believe that "one size fits all. "
Teaching orthodontic treatment mechanics in a
"cookbook fashion " based on Angle's classifica-
tion of malocclusion or tooth relationships alone
results in the clinician focusing on the static rela-
tion of teeth on a plaster model. 1·26 How the teeth
are moved and the materials used to accomplish
these movements become the primary emphasis
of treatment. Nothing could be more contrary to
the goal-directed philosophy.
While it is obvious that each patient is
unique , it often is forgotten that treatment me-
chanics must be tailored to the individual. In ar-
der to create a plan that will provide effective and
efficient treatment, it is important that all aspects
of the patient's problem be considered .
The establishment of an accurate diagnosis
is the first prerequisite in designing treatment me-
chanics. Factors to be considered include facial
balance and aesthetics , skeletal pattern , the den-
tition and its occlusal components , the health and
function of the TMJ , the integrity of the periodon-
tal supporting structures , and the overall health
of the gnathic system. lf the patient is young , the
additional dimensions of time and growth must
be factored into the equation , as the amount and
direction of expected growth will have an effect
on each of the above factors. Whether taken as
a whole or individually, these factors may have a
profound effect on treatment outcomes and must
be taken into account during treatment planning .
lt is inappropriate to use the same treatment
mechanics for all Class 1, Class 11 or Class 111
cases . Each of these classifications may present
in different facial biotypes with different growth
directions and magnitudes, and each would re-
spond in a different way to the same treatment
mechanics. Treatment cannot be the same for a
patient who has a Class 11 malocclusion with a
Class 11 skeletal pattern and a patient who has
a Class 1 malocclusion with a dolichofacial bio-
type. Treatment will differ for a patient who has
a skeletal open bite and/or dental open bite from
one who is a brachyfacial biotype with a skeletal
deep bite.
lf growth is expected , the orthodontist must
determine whether it will aid in the correction of
the orthodontic problem or make the correction
more difficult. ls the lip profile normal or is it re-
truded or protruded? Are extractions required?
What are the anchorage requirements for com-
pleting treatment successfully? These are only a
few of the questions that must be answered be-
fare treatment is begun.
To believe that all patients can be treated
alike and that treatment planning is a simple pro-
cedu re is na'lve. lt is not the shape or color of
a bracket, the alloy of the wire , the sequence in
which it is used , or the shape of its bend that will
result in a successfully treated case . There is no
specific recipe , prescription , or wire with magical
properties that will work on all patients. That there
are so many factors influencing orthodontic treat-
ment suggests that there are no easy cases when
trying to achieve an "ideal" result.
DIAGNOSIS ANO PROBLEM LIST
Traditionally, orthodontists have been in-
terested in wire bending , generating forces in a
desired direction , and watching the teeth move in
349
 Treatment Mechanics
response to their efforts. Although moving teeth
efficiently and effectively is important in accom-
plishing treatment objectives , it is far more im-
portant to thoroughly understand the nature of
the problem being treated ; e.g., the skeletal re-
lationships, how growth will affect treatment, how
the patient's skeletal pattern will affect treatment
mechanics , the limitations of treatment, what to
avoid during treatment, and precisely what tooth
movements will be required .1·26
One of the key tenets of the goal-directed treat-
ment philosophy with regard to skeletal relation-
ships , and a factor that sets this philosophy apart
from that of traditional orthodontics , is that the
assessment is made with the mandible in centric
relation (CR). lf the el inician does not know what
the patient's real mandibular position is, he/she
cannot know whether the patient has a Class 1,
11 or 111 occlusion or an open bite , an increased
overbite , a deviated mandible dueto an asymme-
try, etc. ; treatment could be based on an incorrect
diagnosis . Mounting models on an articulator in
CR can have a profound effect on all aspects of
treatment. 9 •10 ·27 ·28 ln addition , the objective is to de-
velop a mutually protected occlusion in conjunc-
tion with the anatomical characteristics described
by Andrews (see Chapter One). Equally impor-
tant is that treatment goals and expectations be
clear. The concept of treating with defined goals
in mind , knowing what the end result should look
like, and how to achieve these goals are impor-
tant elements in designing a treatment sequence
and the mechanics to be used . This is another
key factor that sets the goal-directed philosophy
apart. According to Dr. Roth , "lf you don 't know
these essential things about your patient, you
could have the most wonderful mechanics in the
world and still fail to achieve a decent result even
though you were efficiently moving teeth ." 1.2.2s
END GOAL OF TREATMENT:
BEGIN WITH THE END IN MINO
Treatment goals generally will include the
following :
• Good facial aesthetics
• Good dental aesthetics
• A functional occlusion
• Good periodontal and TMJ health
350
• Stable treatment result
• Correction of the patient's chief complaint
Each of these goals can be defined , quanti-
fied and measured , the result of which is a set
of measurable criteria by which treatment can be
planned and the results judged .1.2·3-26 For exam-
ple , when evaluating facial asthetics , the subna-
sale vertical line provides a reference by which
the upper lip , the lower lip , and the soft tissue
chin may be evaluated . When designing treat-
ment and outlining the mechanics to be applied ,
this reference may be one of the criteria used to
decide the anchorage requirements for the case .4
Functional occlusion as a treatment goal is
one of the more important contributions of the
goal-directed philosophy (see Chapter 1). lt also
is a fundamental guide in making therapeutic de-
cisions regarding mechanics . lt provides an ideal
occlusal scheme (individual three-dimensional
dental positions , three-dimensional dental arch
form , and intermaxillary dental relationships) that
guides the clinician in obtaining an excellent,
mutually protected occlusion ; it teaches what is
necessary and what should be avoided when
seeking to obtain a seated condylar position . A
basic requirement is to begin from a seated con-
dylar reference position , i.e. , with the mandibular
condyles in centric relation (CR) . lf the goal is to
achieve a centric occlusion that coincides or is
very clase to the mandibular position in CR , di-
agnosis should begin from the seated condylar
reference (see Chapter 6). In addition, treatment
should avoid the use of any type of mechanics
t~at move the condyles out of their seated posi-
tlon such as dental extrusions; transverse arch
incoordination that generates cusp-to-cusp or
c~sp-to-ri~ge contacts ; "hanging cusps, " espe-
Cially max1llary second molars due to inadequate
torque that interferes with the mandibular arch of
closure ; or mechanics that place the mandibular
condyles in unfavorable positions .1-3.s
. The solution may lie in mechanically con-
trollln~ the vertical dimension (restricting of the
extrus1on and dentoalveolar vertical growth
o~ the lateral segments and/or their intrusion)
w1th palatal bars , centric bite blocks , TAOS , or
~one anchors , especially in dolichofacial pa-
tlents , or by obtaining a correct arch width

coordination and/or Wilson curve through the
proper molar and/or premolar torque . The need
for this type of mechanics can be determined by
using mounted casts and the Jarabak cephalo-
metric analyses or by other factors that become
apparent during the initial evaluation of the pa-
tient.
Once the diagnosis has been established , it
is necessary to visualize the means by which the
desired modifications can be made, i.e. , with tooth
movement, by growth, by orthopedic correction of
the maxillary relationships or by a combination of
all of these .2 This requires a study of the occlu-
sion using accurately mounted models in a seated
condylar reference position on a semi-adjustable
or fully adjustable articulator (see Chapter 3). Ar-
ticulator mounted models allow evaluation of the
patient's real occlusion, as dictated by a seated
condylar reference, and shows the premature
contacts or centric interferences that could be
distracting the condyles. 1·3·5·9-15·17·18 ·27 In the ma-
jority of patients, the most frequent interferences
occur in the last molars and most often are due
to a torque problem and/or transverse discrepan-
cy that causes an arch incoordination .18·27 These
data are not attainable with models trimmed in
centric occlusion.
In cases in which the centric discrepancy is
2 mm or greater in either the horizontal or vertical
dimension, the lateral cephalometric radiograph
tracing is converted from a centric occlusion to a
centric relation view (see Chapter 7) . This allows
the clinician to make a cephalometric diagnosis
and a treatment plan based on the seated condy-
lar mandibular position .1·3·26
VTO
To design the correct mechanics for a given
case , a modified version of the visual treatment
objective (VTO) as described by Ricketts and the
five-part superimposition as described by Bench
are used (see Chapter 7). 31-33 This will allow a
quantification of:
1. The necessary amount of growth required to
correct intermaxillary relationships
2. The amount of orthopedic change in the max-
illa and/or change in the mandibular position
Aya/a
needed to correct the relationship between
the dental arches
3 . The amount of desirable and/or possible an-
teroposterior and vertical dental movement of
the teeth in each dental arch Y 6
Traditionally, according to this planning sys-
tem in the goal-directed philosophy, the mandibu-
lar arch most often is treated ahead of the maxil-
lary arch. This is true in the VTO planning as well
as in clinical execution . In building the VTO , the
mandibular incisor is the first tooth to be placed
and is the key to locating the entire denture. In
addition , the mandibular incisor position is de-
pendent upon mandibular position in centric rela-
tion . By treating the mandibular arch ahead of the
maxillary arch , the clinician is able to integrate the
sequence of treatment planning with that of treat-
ment execution . This provides a "road map" for
continually evaluating the progress of treatment
from centric relation. In many cases, it is very dif-
ficult to treat to centric relation without keeping
the mandibular arch ahead of the maxillary arch.
Tria/ Treatments
The advantage of using the VTO is that it
allows 1) the planning process to occur without
physically involving the patient and 2) the clinician
can easily design multiple treatment approaches
with no negative consequences to the patient.
APPLIANCE OF CHOICE
Design
Befare describing the treatment process , a
thorough understanding of the orthodontic appli-
ance used to correct malocclusions is necessary:
in this case , the Andrews straight wire appliance
with its bracket prescription modified by Dr. Roth
to slightly overcorrect tooth position at the con-
clusion of appliance therapy. Dr. Roth maintained
the basic configuration of the brackets and the
desire to achieve Andrew's six keys of normal oc-
clusion .2·19 In 1974, Dr. Roth reported his experi-
ence with the six key guidelines:
lf 1 were to define very simply the require-
ments of an ideal occlusion , both ana-
tomically and functionally, for the natural
351
Treatment Mechanics
dentition , 1 would have to say : lt would
incorporate the six keys with the man -
dible in gnathologic centric relation .3·21 ·26
Dr. Roth considered Dr. Andrews ' innovation
of the straight wire appl iance to be one of the
greatest contributions to the orthodontic spe-
cialty.3
Although the straight wire appliance is by
no means perfect , the minimal amount of error
built into the appliance for most cases is minor
enough to be overlooked in terms of the clini-
cal end product .21 The appliance is designed to
eliminate repetitive , time-consuming , and diffi-
cult-to-reproduce archwire bends , that allow the
clinician to focus on diagnosis and attainment of
predictable results .20 .
A clinician familiar with the six keys imme-
diately recognizes whether optimal occlusion
has been attained . To implement the six keys ,
the orthodontist must understand the definition
of each key (see Chapter One) . In addition , he/
she must understand :
1. The role each tooth plays in static and func-
tional occlusion
2. The effect of tooth and jaw position on arch
form
3. The strategies most suitable for implement-
ing the six keys and correcting the arch
forms .20
In 1979, Roth introduced a bracket setup
with modifications ofthe tip , torque , rotations and
in-out of the Andrews standard setup brackets .
The purpose of the Roth setup was to provide
slightly overcorrected tooth positions in all three
planes of space prior to appliance removal to
allow the teeth to settle , in most instances , into
the optimal positions discovered by Andrews in
untreated subjects with normal occlusions . Roth
found that after appliance removal , there was a
consistent tendency for teeth to relapse and in
considerable amounts . By overcorrecting prior
to appliance removal , any settling would tend to
move teeth towards a normal occlusion and not
away from it. In effect , Roth included overcor-
rection to compensate.for relapse .29
Roth 's basic underlying assumptions were
1) that with appliances in place , it would be vir-
352
tually impossible to pos ition the teeth precisely
into the occlusion seen in the untreated , normal
sample because of bracket interference and 2)
after appliance removal , no matter how good the
end-of-treatment occlusion might be , the teeth
would tend to shift away from that position .25
The overcorrection would allow the clinician to
guide the final settling of the occlusion into the
most optimal position possible while maintain-
ing the desired seated condylar position . lt has
been more than 25 years since this prescription
became commercially available and the effec-
tiveness of the overcorrection has been well
corroborated . Thousands of patients have been
treated successfully with this prescription .
Bracket Placement
At the heart of every good treatment result
is a well-placed appliance , regardless of the
appliance used . This is particularly true for the
straight wire appliance . lt is far easier to control
tooth positions with bracket placement than by
bending wire. 21 The success of the set-up is di-
rectly related to the accuracy of bracket place-
ment. 29
The key to determining bracket height is
the cuspids and the bicuspids (second bicus-
pid in an extraction case) .22 ldeally the center of
the bracket slot vertically, sagittally and frontally
(slot point) should be placed on the midpoint of
the facial axis of the clinical crown known as FA
point (facial axis point) . This axis is located for
all teeth except molars on the most prominent
portien of the central lobe on each crown 's buc-
cal surface ; for molars , the buccal groove that
separates the two large buccal cusps. 20
In a patient with average gingival attach-
ment height, this location would be at the
center of the clinical crown . However, the cli-
nician must take into consideration the height
differential between the size of the posterior
teeth , the cuspids , and the anterior teeth , if
he/she wishes to bracket the case so that it
is possible to level the Curve of Spee with a
flat archwire . Generally, this requires adjust-
ing the height of the cuspid and incisor brack-
ets more incisally. A good guideline is to place
the center of the brackets 0 .5 mm to 1 mm in-
cisa! to the center of the clinical crown in the

six anterior teeth . Roth used this guideline in ev-
ery case regardless of the skeletal pattern.
More recently, Roth modified this approach
for dolichofacial patients with an open bite ten-
dency: In arder to obtain a good overbite in the
six maxillary anterior incisors , the bracket centers
are placed at the center of the clinical crown as
advocated by Andrews. 20 Originally, the maxillary
lateral incisor brackets were placed at the same
height as the central incisor brackets. After set-
tling , the central incisors would be /'2 mm to 1 mm
longer than the lateral incisors. In recent years ,
Roth has changed the bracket position in the
maxillary lateral incisors such that its incisal edge
is 0.5 mm shorter than the adjacent central inci-
sors . Similarly, the cuspid bracket is placed at the
same height of the central incisors. 25· 26
In the molars, the tubes are placed occluso-
gingivally in the middle ofthe anatomiccrown and
not the clinical crown. As demonstrated by Roth ,
an up-righted position of the molar is obtained
with this tube position. 3 ·26 From the occlusal view
point, the center of the tu be lines up mesiodistally
with the buccal groove.
For the rest of the teeth, the brackets are
centered mesiodistally on the prominent buccal
developmental ridge (clinical crown long axis) . In
other words , the center of the slot is lined up with
the maximum mesiodistal convexity of the crown.
Occlusogingivally, this position corresponds to the
center of a normal , fully erupted clinical crown. In
the cuspids , the buccal developmental ridge or
crown long axis is slightly mesial to the center of
the tooth mesiodistally. 22
Again , there is nothing more contrary to
goal-directed thinking than establishing a treat-
ment mechanics sequence as a "cook book" for
the treatment of Class 1, 11 or 111. Every patient
presents a different challenge , and treatment
must be tailored to each patient.
For a better understanding , this chapter will
illustrate a simplified generalization of the treat-
ment sequence in the permanent dentition , which
then can be adjusted to fit a specific patient. Each
stage and its objectives can be applied to extrac-
tion and nonextraction cases , with variations de-
scribed separately.
Aya/a
STAGES OF GOAL-DIRECTED
TREATMENT MECHANICS
Treatment of any malocclusion may be di-
vided into three stages.
Stage 1
As in almost all treatment techniques , the
goals in the first stage are align , level and coordi-
nate the dental arches. Because of the features
built into the goal-directed set-up , the posterior
teeth are up-righted to an "anchorage prepared"
position during this stage. The properties of the
latest generation of wires have allowed for sim-
plification of the treatment sequence while main-
taining forces that stay within the biological rang-
es required for tooth movement, histology, and
periodontal health. 2
Stage 1 objectives are 1) align and level
brackets , to coordinate the dental arches , 2) at-
tain full-bracket engagement of all teeth on a
.020 superelastic NiTi medium or stainless steel
round wire, and 3) clase the spaces between the
incisors and cuspids . Individual tooth movements
are done in Stage 1, while majar or group tooth
movements are done in Stages 11 and 111.
The initial archwires have high flexibility and
low load deflection rates such as .014 superelas-
tic NiTi wires, small braided multi-strand wires or
nickel titanium wires . The most common treat-
ment modality is to begin treatment with thermo
activated .014 wires. As alignment improves,
wires with more resilience and/or stiffness, such
as .020 steel , are used . Elastomeric c-chains may
be used for space closure from cuspid to cuspid.
Brackets are reset as soon as improper tooth
positions are evident. The objectives of Stage 1
are reached when full-bracket engagement is at-
ta ined on a .020 steel wire with no deformation
and the anterior and posterior spaces are closed,
although there may be spacing between the an-
terior and posterior segments. 1·26
Generally, the archwire sequence most
used is superelastic NiTi .014 medium, super-
elastic NiTi .020 medium , and .020 stainless
steel. Stainless steel .020 archwires are used
only when maximum anchorage is needed
to 1) take full advantage of the posterior an-
chorage preparation (distal rotation and distal
353
 Treatment Mechanics
inclination) built into the prescription and 2) obtain
the most leveling possible befare progressing to
rectangular archwires.2 lt is important to remem-
ber that torquing incisors, especially maxillary in-
cisors , is one of the activities that burns anchor-
age.
lnitiating leveling with light wires is designed
to avoid , as much as possible , tooth extrusion that
may cause an opening of the facial axis and/or
condylar distraction . Forces generated by these
archwires are not strong enough to overcome
the forces of occlusion . As a result, the intrusive
movements that require a light force will prevail
over the extrusive forces in the leveling process.
This is especially important in dolichofacial pa-
tients who have a short mandibular ramus and/or
an open angle at articulare , as defined by the Ja-
rabak analysis , or patients who start orthodontic
treatment with a large condylar distraction.
Unlike other techniques , opening the facial
axis to open the bite is a treatment goal rarely cho-
sen in the goal-directed philosophy. This concept
is best understood when patients are diagnosed
from a seated condylar position using models
mounted in a semi-adjustable articulator. In effect,
experience and research have shown that a great
majority of patients exhibit an open bite or inad-
equate overbite when placed in the seated con-
dylar position. 5 ·9- 10 · 18 ·27 The most common goal in
the goal-directed treatment philosophy is to close
the facial axis in arder to achieve correct anterior
guidance, competent lip closure and chin projec-
tion , all in harmony with a seated condylar posi-
tion . lnitiating treatment with square or rectangu-
lar wires of a higher load deflection antagonizes
this treatment goal. Moreover, leveling gradually,
i.e. , starting with small flexible round wires and
changing to increasingly higher load deflection
wires , produces a small , progressive increase in
force levels that are in harmony with dental move-
ment and decreased patient discomfort.
In dolichofacial patients with a deep man-
dibular Curve of Spee and/or a maxillary inverted
curve due to the extrusion of the incisa! group, a
different method is used to avoid or reduce molar
and premolar extrusion . Utility arches formed from
354
.019 x .019 blue elgiloy wire and placed in the
.022 slot provide the appropriate intrusive force
(1 00 gm to lift the mandibular incisors and 150
gm to lift the maxillary incisors). The tipping effect
of utility arches on molars is offset by the use of
lingual arches , transpalatal bars (TPAs) or heavy
bucea! section wires in the main archwire slot. 1·26
In general , patients with a dolichofacial skeletal
pattern , especially the more severely affected
patients , constitute a separate group that should
be treated with special considerations related to
therapeutic decisions and the selection of appli-
ances to be used .
Stage 11
After 8 to 1O weeks of treatment with .020
superelastic NiTi archwires, the second stage
(often called the work stage) of treatment is be-
gun . In this stage , .018 x .025 superelastic NiTi
archwires are used resulting in further, but limited ,
space closure . These archwires will produce an
almost complete distal inclination and rotation of
molars and premolars . Additional objectives of
these rectangular archwires are to complete the
leveling and start a progressive increase in torque
control. Once this has occurred, space closure us-
ing straight archwires will stop. Further space clo-
sure will need to be done with closing mechanics.
Depending on the inclination or torque of
the incisors required , the use of rectangular wires
may cause a loss of anchorage in the bucea! seg-
ments. As stated earlier, torquing the upper inci-
sors is one of the activities that may "burn anchor-
age ," especially in dolichofacial patients. Because
of this and when indicated by the diagnosis and
treatment plan , TPAs are placed at the same time
to gain more molar anchorage . The preference is
to place the TPAs after most of the inclination and
distal rotation of the molars has occurred . This
avoids the conflict between the action of the arch-
wires and the TPAs .
Approximately six weeks after superelastic
NiTi .018 x .025 archwires have been placed , .019
x .025 stainless steel archwires or .019 x .025 dou-
ble keyhole loop (DKL) archwires may be placed .
This will allow completion of the leveling process
and , where necessary, start the active closure of
the remaining spaces .

The goals of Stage 11 are to :
Accomplish all majar anteroposterior, trans-
verse and vertical group tooth movements
Coordinate arch width and symmetry
Correct cross bites
Correct overbite and overjet
Retract protrusive anterior teeth
Move bicuspids and molars forward or prevent
their forward migration as indicated
lntrude maxillary molars and bicuspids
lntrude lower incisors as indicated
Correct the Class 11 or Class 111 molar relation
Clase the remaining spaces
Stage 11 movements are mainly translation and
root tipping and/or torquing. 1·3.2 6
The archwires used for Stage 11 movements
have low flexibility and high load deflection rates ,
but they can be resilient or springy. Space clo-
sure usually is done with DKL archwires (six an-
terior teeth are retracted as a group ).1•3 •26 After
extraction-site closure , it typically is necessary to
return to more flexible wires such as .018 x .025
superelastic NiTi for leveling. The goals of Stage
11 are reached when the movements listed above
have been completed .
The archwire used most in this stage is the
.019 x .025 DKL wire introduced by Dr. John
Parker. lt 1) allows complete space closure with
one wire per arch , 2) serves as a reasonable
mean between tipping, sliding and bodily move-
ment mechanics and 3) selectively clases spaces
as necessary from the front to back or from the
back forward. 2 DKL archwires may be formed
from .019 x .025 or .021 x .025 stainless steel or
blue elgiloy, .019 x .025 or .021 x .025 and oc-
casionally .020 stainless steel . Each one of these
has specific applications that are explained later
in this chapter.
Andrews found in his ideal occlusion sample
that all teeth have a mesial inclination that varies
in magnitude according to the tooth . In the poste-
rior segments during the settling that follows ap-
pliance removal , teeth incline and rotate mesially.
After two years of trial and error, Roth found the
answer to the question of how much overcorrec-
tion is needed to ensure that teeth would move
Aya/a
from an over-treated position to the position found
in Andrews ' untreated ideal sample .
The goal-directed appliance produces, among
other effects, distal inclination and rotation of
maxillary and mandibular molars and premo-
lars .2 This makes it possible to obtain an efficient
anchorage preparation in the buccal segments
that minimizes anchorage loss without, for the
most part, using headgear. However, in cases in
wh ich the VTO treatment plan calls for anchor-
age loss through mesial movement of the buccal
segments , th is anchorage preparation can be a
problem . In these cases, it is necessary to take
special measures to ach ieve the desired move-
ments .
Figure 1 is a comparison of the features of
the Andrews and Roth set-ups that illustrates the
modifications introduced by Roth . The over-cor-
rections also are a way of handling the play or tip-
ping freedom between the archwire and bracket,
which reduces the effectiveness of the tip, torque ,
and rotation features that are "built in" the slot.2 9
This is especially important in the second phase
of the goal-directed treatment mechanics where-
in most of the three-dimensional tooth move-
ments take place and generally with .019 x .025
wires .
Arch Coordination. The use of rectangular
archwires facilitates the transverse coordination
of the arches , which is achieved by the trans-
verse coordination of the maxillary and mandibu-
lar archwires. This coordination also requires ad-
equate molar and premolar torque to permita cor-
rect alignment of occlusal mesiodistal grooves.
Considering that the torque or molar inclination
found by Andrews in his untreated normal sample
was 1oo , it is evident that the bracket slot must
be filled to achieve an overcorrection. This salves
the interferences caused when the lingual molar
cusps hang down due to a positive torque and/or
an exaggerated Wilson curve.
With .019 x .025 archwires , there is a buc-
colingual "play," i.e. , a loss of effective torque of
7.2°. With .021 x .025 archwires , the loss is 2.3°
and with .0215 x .0275 archwires , the loss is 1°.
A maxillary molar tu be with 14 o of torque would
produce torque of 6.8°, 11 .r and 13° respective-
ly for the above listed archwires.29 lt also is pos-
355
Treatment Mechanics

l~~~\!~ ~,~,,~eC\~
5' 5' 2' 2' 11 ' 9' 5' -9' - 9' - 7' -7 ' - 7' 3' 7'

Ji! j 1' 11 t ~~ {t t'f(

:1~1l\l~ ~,~,~C'C \~
~ 11 tr,.·r r f ~:~ t t ~'..fr
Figure 1. Tip Andrews (top left) and torque Andrews (top right) . Tip Roth (bottom left) and torque
Roth (bottom right) .
1-
Angulatlon U 1 2 3 4 5 6 7 sible to achieve the desired torque with archwire
torsion or the use of TPAs , but these mechan-
Andrews so go 110 20 20 so so
ics lack the precision and consistent results
Roth so go 13° oo oo oo oo that can be achieved with the built in prescrip-
Angulatlon L 1 2 3 4 5 6 7 tion of the goal-directed straight-wire appliance .
Andrews 20 20 so 20 20 20 20 Stage 111
Roth 20 20 70 -1 o -1 o -10 -1 o Stage 111 is the detailing and finishing stage .
lncllnatlon U 1 2 3 4 5 6 7 The goal is to use a full-size rectangular archwire,
without any bends other than that of the arch form ,
Andrews 70 30 -70 -70 -70 _go _go
to realize the total expression of the features in
Roth 12° so -20 -70 -70 -14° -14° the bracket set-up , thereby achieving the final
lncllnatlon L 1 2 3 4 5 6 7 treatment detailing and tooth position.

Andrews -10 -10 -110 -17° -22° -30° -3S0 After finishing Stage 11 and reaching a Class
-10 -1 0 -170 -22°
1 occlusion , a .021 x .028 superelastic NiTi arch-
Roth -11 ° -30° -30°
wire can be used to preclude the posterior use of
Rotatlon U 1 2 3 4 5 6 7 a .021 x .025 steel archwire. Befare a .021 x .025
Andrews oo oo oo oo oo 1QOO 1QOO steel archwire is placed , bracket position should
oo oo be checked and brackets reset as necessary to
Roth 4°M 2°0 2°0 14°0 14°0
correct and adjust the tooth positions .1·3 ·26 -29 Todo
Rotatlon L 1 2 3 4 5 6 7 this , new impressions must be taken and a new
Andrews oo oo oo oo oo 4°0 4°0 articulator mounting done. This allows 1) the po-
sitian of the bands and brackets to be checked
Roth oo oo 2°M 2°M 4°0 4°0 4°0
accurately so that premature contacts interfer-
Figure 1. Continued . ing with the correct occlusion can be identified,

356

2) the correct arch width coordination to be
checked and 3) in general , the tooth movements
needed to achieve the final goal of a mutually pro-
tected occlusion in CR to be determined. Mounted
models provide a far more accurate view of the
occlusion (especially lingually) and the mandibu-
lar position than that observed in the patient. This
is why articulator mountings are continued dur-
ing Stage 111 until the desired results are attained .
After bracket repositioning , lower load deflection
archwires are placed (e.g., .018 x .025 NiTi ora
.020 superelastic NiTi ) to relevel the case . After
releveling , a .021 x .025 steel wire is used for sev-
era! months (normally three) until the full bracket
prescription has been expressed.
Final archwires can be .021 x .025 braided
wires or smaller dimension wires can be used to
allow optimum setting of the teeth . During this
stage, special attention must be paid to dolicho-
facial patients for whom the use of heavy wires
should be avoided. With this facial pattern , it
would only take one bracket wrongly positioned
for a premature contact to occur that could pro-
voke an open bite , a condylar distraction , or both.
Therefore, it is advisable to reach final tooth posi-
tions with lower deflection archwires (e.g. , 021 x
.028 superelastic NiTi) ora .021 x .028 steel wire
in the maxilla (where more torque is required)
Figure 2. Pretreatment facial and intraoral photographs .
Aya/a
accompanied by a low deflection archwire in the
mandible such as a .021 x .028 braided wire.
Stage 111 is finished once a Class 1 mutually
protected occlusion in CR is obtained as mea-
sured on casts mounted on a semi-adjustable
articulator. Clinical examination of the final result
typically reveals only a mandibular accommoda-
tion that hides the patient's real occlusion . This is
because the patient's neuromusculature is strong-
ly programmed to close the mandible to the best
tooth fit (see Chapter One ).28
CLINICAL EXAMPLES OF TREATMENT
Due to their different biomechanical needs
and looking for a more didactic modality, the clini-
cal case presentations are divided into extraction
and non-extraction treatments.
Nonextraction Treatment
The first patient (Figs. 2-4) is a 16-year-old
female patient, whose chief complaints were fa-
cial pain and spaces present between her ante-
rior teeth. The patient's history and the clinical
examination confirmed that there was a mild sen-
sitivity to palpation of the masseter and anterior
temporalis muscles bilaterally that appeared to
be related to a nocturnal centric clenching habit.
357
 Treatment Mechanics

•
• ,_
'
-

Figure 4. Pretreatment CPI record .

Figure 3. Pretreatment models mounted in centric re-
lation.

This muscle hyperactivity also caused a moder-

ate alteration in mandibular dynamics. She did
not present with any interna! joint signs or symp-
toms . The presence of muscle symptoms and a
difficulty in manipulating the mandible suggested
that a maxillary, total coverage repositioner splint
be placed as part of the diagnostic evaluation. The
objective of this would be 1) to produce a neuro-
muscular quieting that would allow the mandibular
position to be stabilized in the seated condylar ref-
erence position and 2) to determine whether there Figure 5. Maxillary repositioning splint.
was any relation between the occlusion and the
clenching habit that was responsible for the mus- Facially the patient does not present with sig-
ele symptoms (see Chapter 8). 1.3 nificant problems , but her smile evidences the
aesthetic problem that is her concern. Her facial
The splint creates a mutually protected oc-
thirds are harmonic and her lips and mandibular
clusion (bilateral multiple points of contact of the
position are within normal ranges . The intraoral
same intensity on each occluding tooth , and har-
photographs in centric occlusion show a Class 1
monious incisal and canine guidance) and allows
malocclusion with diastemata , an upper midline
a clinical determination of whether the muscle
deviated to the right and an unfavorable inser-
symptoms are related to the occlusion (Fig 5). lf
the splint relieves the muscle symptoms , elimi- tion of the lower labial frenum . Models mounted in
centric relation show a decrease in overbite , an
nates the clenching habit, and allows the condyle
to seat into the fossae , it is evidence that there is increase in overjet and a slight Class 11 malocclu-
sion (see Chapter 6).
a relationship between muscle problems and the
malocclusion. This sug-gests that treatment incor- Stage l. After successful splint therapy, the first
porating correction of the occlusal relations would stage of orthodontic treatment is begun with super-
help salve the patient's chief complaint. 1.3 elastic NiTi .014 medium force archwires, tightly

358

Figure 6. Patient with maxillary and mandibular .014 medium superelastic NiTi archwires (A) ; .020 medium
superelastic NiTi archwires (8); .018 x .025 superelastic NiTi archwires (C).
cinched back at the distal end of the second mo-
lar tu bes (Fig. 6A). One of the most common find-
ings in patients seeking orthodontic treatment is
that molars and premolars are mesially inclined
and rotated far more than found in Andrews '
untreated ideal occlusion sample . The features
built into the brackets and tubes of the prescrip-
tion will move these teeth into an overcorrected
position , which includes the teeth being distally
inclined and rotated . The cinched back wire dis-
tal to the second molars allows the retraction
of the six anterior teeth while the distal rotation
and inclination of the buccal segments is taking
place. The round wire will produce retroinclina-
tion of the incisors without loosing anchorage;
this occurs as a result of the distal inclination
and rotation of molars and premolars. lncisor re-
trusion will occur only if there is available space
or if the distal rotation and inclination of molars
and premolars generates the necessary space
for it to occur. This provides an efficient anchor-
age preparation of the buccal segments that will
resist future mesial movement and anchorage
loss.
lf retraction of anterior teeth is not necessary,
the archwire is bent approximately 2 mm distal to
the second molar tu be or is cut at the distal end of
Aya/a
the second molar tube and allowed to slide freely.
lf there is no space or a negative arch length dis-
crepancy (-ALD), incisor retraction will not occur;
instead, the incisors will tend to protrude approxi-
mately 50% of the -ALD.
An important aspect of Stage 1is dental mid-
line control, which in this case did not require any
specific action. When there are spaces available ,
a commonly used technique is to place a stop
(often a light cured composite stop) distal to the
lateral or the cuspid on the side opposite to the
side to which the midline must move. The teeth
will slide to the space. This system is practica!
and easy, but the stop must be placed in a curved
zone in the archwire to prevent it from moving .
Early midline control avoids an increase in the
deviation or prevents spaces from being closed
and leaving midlines still deviated, which is even
worse. Befare closing the spaces actively or al-
lowing spontaneous closure , the midlines should
be corrected and the spaces consolidated.
Supereiastic NiTi .014 archwires allow an
easy dental sliding with .022 x .028 brackets ,
especially with self-ligated brackets. This wire
is left in place until alignment of teeth is com-
plete or nearly complete; in most cases, leveling
359
Treatment Mechanics
will not have been completed . Leveling finally will
be achieved by increasing the size and resiliency
of the wires . With most self-ligating interactive
brackets , the clip will engage only when .018 or
larger wires are placed , so when using .014 wires ,
sorne teeth will not complete their alignment, and
will do so only when the archwire size is increased
and an interaction between the wire and the inter-
active bracket clip occurs.
During this period , the patient is seen ev-
ery five to six weeks. Treatment time with this
first archwire will depend on the initial amount of
crowding , but rarely exceeds four months.
Figure 68 shows the patient with .020 medi-
um superelastic NiTi archwires newly placed in the
maxilla and mandible after three months of treat-
ment with .014 superelastic NiTi wires . Notice
that the upper and lower spaces have decreased
due to the incisor retraction produced by the distal
rotation and inclination of posterior teeth . Notice
also the improvement in the overjet/overbite rela-
tion and the improvement in the maxillary dental
midline. The overbite improvement may be dueto
a mandibular accommodation and the loss of the
centric relation position that was achieved during
splint therapy. lt is important to check mandibu-
lar position by manipulating the mand ible to the
centric relation condylar position every time the
patient is se en .
The .020 heavy superelastic NiTi (or small-
er as the case requires) , which partially fills the
bracket slots and tubes , causes the built-in dis-
tal rotations and inclinations to be expressed ,
thereby producing the retraction of the six anterior
Figure 7. Patient with maxillary .019 x .025 stainless steel archwire and mandibular double keyhole-loop .019
x .025 archwire (A) and with maxillary and mandibular .021 x .025 braided archwires (8).
360
teeth. This retraction , produced by the features
built into the prescription , frequently moves the
incisors closer to the desired cephalometric posi-
tion . This will decrease or eliminate the need for
active incisor retraction . Figure 6C shows what
was obtained with the .020 superelastic NiTi arch-
wires : the space closure continued and a correct
overbite/overjet relation was established . Stage
1 is finished when the .020 superelastic NiTi (or
.020 steel in cases of maximum retraction) arch-
wires have completed all alignment and most of
the leveling . At this time , .018 x .025 superelastic
NiTi archwires are placed to start the next stage
of treatment.
Stage 11. Stage 11 begins with the placement
of rectangular archwires , such as a .018 x .025
(200 gr.) superelastic NiTi (Fig. 6C) , in order to
finish leveling the teeth . Once the leveling is com-
plete , stainless steel .019 x .025 archwires are
placed (Fig 7A) . lt is with these increased de-
flection forces and with the teeth completely lev-
eled that three-dimensional movements can be
achieved ; the rigidity of the wires allows the teeth
to be moved as a whole (or with a sliding motion)
without deforming or collapsing the arch , which
can occur with less rigid archwires. In this case,
a .019 x .025 stainless steel , double keyhole-loop
archwire was used in the mandible to clase the re-
sidual spaces. lt is important to remember that the
leveling process must be completed befare any
closing movement is initiated .
Stage 111. Once spaces are closed anda Class
1 occlusion with normal overjet/overbite relation
has been achieved , it is desirable to use .021 x
.028 superelastic NiTi or similar archwires as an
 Aya/a

intermediate step before using stainless steel
.021 x .025 archwires. Before placing steel arch-
wires , new casts should be mounted on the artic-
ulator to continue treatment planning and to iden-
tify brackets that need to be repositioned . The
.021 x .025 steel archwires generally are main-
tained for three months in order to completely ex-
press the characteristics included in the bracket
prescription. The finalization stage proceeds as
usual , with maxillary and mandibular .021 x .025
braided archwires (Fig . 78) and heavy 1/8 elas-
tics placed in a triangular fashion from the first
maxillary bicuspid to the mandibular bicuspids.
Figures 8 through 16 present review and fol-
low-up of the case. Transverse dimensions were
maintained (Fig. 11) with the exception of a minor
change in molar arch width .

Figure 8. Patient in Stage 1(A), Stage 11 (8), and end of Stage 111 when the appliances were removed (C).

1 ••• 1 1 •••
1 1 1. 1 1. 1.
1
·~·1
1 1.1 • •
.....
..... .........
1. 1.' 1·~
1 •••• •••••
1.1. 1 • 1 •••

.........
1 ••• 1 1 •••
• • • •

1 1 1. 1 1 •••
1 1 1.' 1. 1.
1 ••••
1..
• ••• 1

1 ••••
1 1 ••••
•••• -

•••••
•• 1.1 1.1 • •
• • 11 11 • • •
• ••• ' 1"

• ••• 1 ••••
1 ••• 1 1 1 ••
1.111 11 • •
. 1.1. 1 • 1.1 •
• ••• 1

1 ••• 1
1.1 •• 1 • •
•••••

•••••

1.1 • • • • •
1.
1.
~~~ ~~~~ ~~~~~~~o·~ ~o··~~~~~~ ~~~~~~~A
•······ ...... .
looilll 1111 1111 1 1 1 • 1
. ..... ·······w
1•111 1111 11111 IIÍI . . .

.................. ......... ......... ..........

1 •••. 1. 1.
1 ••• ' •• 1.
1 •• 1 •••••
1 1. 1 1 1 1 ••
1. 1. 1 1 •••
1. 1 1 1 1 •••
1 •• •••••••
1 ••• 1 ••• 1 •

..... ·o
• •• 1 ••••• 1 •••• •••••

• ••• 1 1 •••
• • • 1 111 • • 1. 1 1 1 1 •• 1
1 1 1. 1 1 1 •• 1 1 1 ••• 1 1. 1 1 1 ••• ·o·~····
1 1 1 •• 1.
111111~ • 1111 . . . . . 11111 . . . . . 1~ .11111.

-
~

Figure 1O. Post-treatment CPI showing that condylar

distraction is within the acceptable range (see Chap-
Figure 9. Post-treatment mounted models . ter 6) .

361
Treatment Mechanics

Figure 11 . Comparison of transverse dimensions taken pretreatment (top) and immediately post-treatment (bottom) .

Figure 12. lntraoral photographs taken two years post-treatment.

Figure 13. Occlusal view two years post-

.
treatment.

Figure 15. Braided archwires work well during finishing

(often with interarch elastics) because they promote
fine tuning of the occlusion .

Figure 14. Mandibular excursions . Top : right

lateral excursion-working and balancing
side. Middle : left lateral excursion-balancing
and working side. Bottom: protrusive excur-
sion-right and left side .

362
 Aya/a

Figure 16. Facial and intraoral photographs taken three years and ten months post-treatment.

In order to obtain anterior guidance in pro-
trusive mandibular excursions without interfer-
ences, a proper incisor overbite/overjet relation-
ship is needed. An incisor overbite of 4 mm and
overjet of 2-3 mm are guidelines appropriate for
most cases (Fig. 17).24 Guidelines for cuspid over-
bite and overjet are 5 mm and 1 mm respectively.
Obviously, fixed norm values for correct overjeU
overbite are not always used , as some patients
will have an appropriate anterior guidance with an
overbite that is less than the guideline. This de-
pends on different occlusal determinants such as
angle of the eminence, inclination of the occlusal
plane , etc. (see Chapter 1).
During lateral test movement, the mandible
often experiences a bodily lateromedial move-
ment known as the Bennett movement or man-
dibular sideshift. This bodily shift occurs early in
the lateral movement, and is especially important
on the balancing (nonworking) side. Cuspids ide-
ally should be positioned to facilitate , not impede,
this movement. For this reason , dental bioesthet-
ics (see Chapter 21) suggests that cuspids have 1
mm of overjet (Fig . 17). Cuspids coupled with no
overjet can interfere with the Bennett movements
and may cause enamel wear or a collapse that
could result in mandibular incisor crowding (Fig.
17).

Figure 17. lncisors with a 4 mm overbite and 2-3 mm overjet. Cuspids with a 5 mm overbite and
1 mm overjet. Cuspids with a 5 mm overbite but no overjet, which is an undesirable occlusal
scheme. Cuspids with 13° of angulation and a 4 to 5 mm overbite.

363
 Treatment Mechanics

Figure 18. Left: Molar tubes positioned in the middle of the anatomic crown occlusogingi-
vally and parallel to the occlusal plane . Right: Placement of the maxillary molar tube more
gingival in the distal end , which is a mistake .

Goal-directed philosophy also recommends
that maxillary cuspids have a mesial inclination of
13° so the cuspid tip occludes in the distal third of
the buccal face of the mandibular cuspid . A 4 to
5 mm overbite will generally place the tip of the
maxillary canine at the level of the contact point
between mandibular cuspid and bicuspid (Fig .
17). All of these factors influence whether an ad-
equate disocclusion is achieved during lateral ex-
cursions .
General Considerations
There are several important considerations
regarding molar position. Roth recommended that
the maxillary molar tubes be positioned in the mid-
dle of the anatomic crown occlusogingivally and
parallel to the occlusal plane of the molar, which
is obtained by an imaginary line joining the tips
of the buccal cusps . This is different from other
teeth in which the brackets are positioned in the
middle of the clinical crown occlusogingivally.2
Thus , for a molar with a 7 mm anatomical crown ,
the tube must be placed 3.5 mm from a line be-
tween the two buccal cusps tips and parallel to
the line (Fig . 18).
One of the mistakes to avoid with maxillary
molars is placing the tube too far gingivally at its
distal aspect (Fig . 18), as this may cause extru-
sion of the distal cusps (Fig. 19) and increase the
potential for interferences during mandibular ex-
cursions . In addition , the resulting mesioinclina-
tion creates a loss of anchorage and poor resis-
tance to mesialization force.

Figure 19. Misplacement of the maxillary molar tube may cause the ex-
trusion of the distal cusps .

364

To measure the amount of tip to the crowns
of the maxillary molars, Andrews used the buccal
groove that separates the mesial and the distal
buccal cusps (Fig . 20). He found in his untreated
normal sample that the crowns of the maxillary
first and second molars were mesially tipped 5°
to the occlusal plane. To achieve a molar uprighting
with its concomitant improvement in molar anchor-
age , one of the variations added to the original
goal-directed mechanics is placing the maxillary
molar tube perpendicular to the buccal groove. In
order to do this , the distal portian of the tube is po-
sitioned 0.5 to 1 mm more occlusally and the me-
sial portian is placed vertically in the middle of the
anatomical crown (Fig. 21 ). The same can be ap-
plied to the mandibular molar tubes in maximum
anchorage cases. Figure 22 illustrates the differ-
ent positions obtained by placing the molar tube in
the way that was just
described and plac-
ing the tube parallel
to the occlusal plane ,
which results in a 5°
mesial tip.
The next case il-
lustrates such a varia-
tion (Figs. 23-34 ). The
patient was a 10-year,
11-month-old male.
Figure 20. Andrews used the buccal groove
that separates the mesial and distal cusps
to measure the crown inclination of the max-
illary molars.
Aya/a
Figure 22. The new (Jeft) and standard (right) tube place-
ment.
His main complaint was incisor crowding in the
mandible. Because the permanent dentition was
not yet complete (Fig . 24), the patient was put on
recall until second molar eruption was complete
(Fig. 25). When eruption was complete, full appli-
ance treatment was begun (Fig . 26).
The fontal facial view (Fig . 23) shows a dis-
crete facial asymmetry with the mandible devi-
ated to the right. The profile shows the upper lip
positioned at its retrusive limit sagittally (which
indicates that any movement causing incisor re-
traction should be avoided) and the chin is slightly
retruded .
In Figures 26-29, it is possible to see the
maxillary and mandibular tube positions with their
distal portian closer to the occlusal and the result-
ing molar uprighting. Though not visible in the fig -
ures, clinically the distal cusps of the molars are
slightly out of occlusion at the end of treatment.
This variation in maxillary molar tube place-
ment is indicated especially in cases of maximum
anchorage, because the molar uprighting obtained
in this way improves anchorage , which increases
resistance to mesial movement.
Figure 21 . To achieve a molar upright-
ing to oo , the mesial portian of the tu be
is positioned vertically in the middle of
the anatomical crown and the distal
portian 0.5 to 1 mm more occlusally.
365
Treatment Mechanics

Figure 23 . Pretreatment facial photographs .

Figure 24. Pretreatment intraoral photographs . Figure 25. lntraoral photographs taken 1.5 years later
when the permanent dentition was completely erupted.

366
 Aya/a

Figure 26. Patient with maxillary and mandibular .014 superelastic NiTi archwires.

Figure 27. Patient with .018 x .025 superelastic NiTi archwires.

Figure 28 . Patient with .021 x .025 braided maxillary and .019 x .025 stainless steel mandibular archwires.

Figure 29. Patient with 0.21 x 0.25 braided maxillary and .019 x .025 stainless steel mandibular archwires two
months later.

Figure 30. Comparison of beginning treatment (top) and the end of treatment (bottom) .

367
Treatment Mechanics

Figure 31 . In centric occlusion , a .0005" shimstock is held by the posterior

teeth , but the anterior teeth , with a very light contact, are not able to hold
the shimstock: the mutually protected occlusion concept (see Chapter 1).

Figure 32 . Post-treatment facial and intraoral photographs.

/
7 °"
Nasion-Basion@ ce
N . B . @
__.., .
3510
"
Profile

Figure 33. Superimposition of initial (black) and two-year post-treatment (red) ceph images. Tracings have
been converted from COto CR (see Chapter 7).

368
 Aya/a

The following patient is a 16-year-old female

who 's main concern was the spaces between her
teeth due, in large part, to a tooth size discrep-
ancy, especially the small maxillary lateral inci-
sors. In this case , in order to have a stable final
result, treatment could not reduce the arch length
by retruding the maxillary and mandibular incisors.
Therefore, once leveling of the maxillary and man-
dibular arches with .019 x .025 wires was com-
pleted during Stage 11, composites were added to
the maxillary lateral incisors to give them an ap-
propriate width temporarily. The remaining spaces
then were closed with elastomeric chains placed
between the maxillary and mand ibular canines.

Simultaneously, the maxillary and mandibu-

lar bicuspids were moved mesially with medium
force superelastic NiTi open coil springs placed
between the maxillary and mandibular 6s and 5s.
The mandibular molars then were moved mesially
with elastomeric chains placed first from 6-to-6 and
then from 7-to-7. To avoid retrusion of the man-
dibular incisors and canines, medium force, 1/8"
Class 11 elastics were used between the maxillary
canines and mandibular second bicuspids. Once
the mandibular molars were in place , the maxillary
molars were moved mesially in the same manner
using Class 111 elastics when necessary. A sum-
mary of the case is seen in Figures 35 through 46.

Figure 34. Post-treatment mounted models.

Figure 35 . Pretreatment facial and intraoral photographs.

369
Treatment Mechanics

+ +

+ +
X X
z z

Figure 37 . Pretreatment CPI.

.Figure 36. Pretreatment mounted models .

Figure 38. Pretreatment intraoral photographs .

Figure 39. Patient with maxillary and mandibular .014 medium superelastic NiTi archwires.

Figure 40 . Patient with maxillary and mandibular .018 x .025 superelastic NiTi archwires.

370
 Aya/a

Figure 41 . Bicuspids being moved mesially using .019 x .025 stainless steel archwires .

Figure 42 . Mandibular spaces closed ; maxillary molars moving mesially; .019 x

.025 stainless steel archwires.

Figure 43 . Patient with maxillary and mandibular .021 x .025 braided archwires.

Figure 44. Comparison of beginning treatment, mid-treatment and post-treatment intraoral photographs.

371
 Treatment Mechanics

Achieving maximum , moderate or minimum an-

chorage requires the planning and execution of
efficient and effective mechanics . Frequent fail -
ures due to over-retraction of the anterior teeth
with the concomitant deterioration of facial aes-
thetics , probably explains the nonextraction ten-
dency that has been a characteristic of the spe-
cialty over time. lt seems that the main goal of
some orthodontic treatment techniques is to avoid
extractions at all costs , even at the expense of
any or all of the following : anterior guidance, peri-
odontal health , TMJ health , facial aesthetics and
stability. Treatment planning should always strive
to achieve as many of the orthodontic goals as
possible. Extraction or nonextraction is a treat-
ment plan , nota treatment goal (see Chapter 16).
For a better understanding of extraction
Figure 45. Post-treatment mounted models .
treatment mechanics , two concepts of goal-di-
rected philosophy will be reviewed : 1) reciproca!
·~·
• • • • • • 111 1 .1111 1~ 1 11111 1111 •

..... .... .........

• • • • 1 •••• 1
•••• 1 •••• 1

•••• 1 •••• 1
'
1
• ..
1 ••••
1 11113
1 1 ••

3 ......... .........
::::: ::::=
1 ••••
••••
• • •
• • • • 1. "
- ••••••••
• • • 1
1
1

'
1 ••• 1 •••• -

~
anchorage mechanics and 2) differential anchor-
age mechanics.

ro::::::·.. ......
.::::
....."01 ro: :::: : .
••••••••• 1 • • • • 1 ••• • ••• 1 •••• 1 •••• 1 ••••
• • • • 1 1 ••• 1 1. • ••••• • •••••••• 1 1 • • • 1 11 • •
• ••• 1 •••• 1

• - •• 1 • 1 •• § 1 1. ;~~~; ~~, • - •• 1 •••• 1

Reciproca/ Anchorage Mechanics. Anchor-
age can be defined as the resistance that a tooth
......... ...... s -- ....... .........
• 1 1 •• -
•••• 1 •••• 1 • ••• 1 •••• 1 1 ••• 1 ••••
• • • • 1 •••• 1 • 1 •••• • ••• 1 •••• 1 1 ••• 1 ••••
or a group of teeth provides in opposition to
..... ·o
'

·o· ....
•••• 1 ••••

- ••• 1 •••• ••••••••• 1

• • • • 1 • '
•
•
1 1 •••
1 1 •••
•
•
••• 1
••• 1 ••••
•••• 1
1 • 1 1 •••
movement. According to Proffit, this term also is
IIIU u _• . u u lu.J lu.JI UIU ILLJ U l l defined in its orthodontic application as the "resis-

-
~

-
~ tance to an undesired dental movement," refer-
ring more to the control of the mesial movement
of the bucea! segments from which forces to the
anterior segmentare applied .3°For every desired
action , there is an equal and opposite reaction .
Therefore , the orthodontist must consider, plan
and carefully control the reciproca! effects that
result from the application of a force on the teeth
that are moved as well as its effect on the teeth
from which the force was applied .
Figure 46. Post-treatment CPI.
This principie of action and reaction is par-
Extraction Treatment ticularly important in the tooth alignment of the
anterior segment. In goal-directed philosophy,
There is little doubt that extraction treatment this is known as "reciproca! anchorage ." In effect,
is a biomechanical challenge of substantial dif- reciproca! anchorage involves the antagonistic
ficulty for the orthodontist, with each treatment and reciproca! forces that develop when a wire is
protocol differing according to the clinical case placed in every bracket in an area of tooth crowd-
characteristics. The precise management of ing . Imagine, for example , an extraction case
extraction spaces with regard to the amount of with anterior crowding . When a round wire with a
desired retraction of the anterior segments and small diameter and low load deflection is placed
consequent mesialization of the bucea! segments in every bracket slot, the resultant forces will pro-
are the keys to obtaining a good treatment result. duce a distalization of the canines (and in the

372
 Aya/a

cases of second premolar extractions, a distal-

ization of first premolars and canines) , which will
resolve the anterior crowding. 3 The small diam-
eter wire allows easy, low friction sliding as it cor-
rects the inclinations and then uprights the teeth.
This is especially true with the use of self-ligated
brackets since friction is greatly reduced by the
elimination of elastic or wire ligatures. Figure
47 presents an example of reciproca! anchorage
mechanics. When a light force archwire (e.g ., a
.014 medium force superelastic NiTi) is placed
in every bracket slot, there is a force pulling the
right lateral incisor labially, but since there is no
space for the tooth, it does not move. Similarly,
there are antagonistic and reciproca! forces be-
tween the two central incisors with no space for
tooth movement. These reciproca! forces are
generated throughout the anterior segment, and
since the canines are the only teeth with available
space, they will move distally.
In this way, space will be created, and the
alignment of each tooth of the anterior segment
will occur without the need for applying any distal-
izing force such as that provided by coils, elastic
chains , or wire segments . lf force is applied from
the buccal segments, it will tend to produce a loss
of posterior anchorage and a forward movement
of the posterior teeth. A significant difference in
the goal-directed prescription is that molars and
premolars are distally inclined and distally rotated
during Stage 1 mechanics, and with this anchor-
age preparation, the position of the buccal seg-
ments is maintained, or, in some instances, the
anterior segments are retracted. The amount of
anterior retraction depends on the amount of ini-
tial mesial molar rotation. To ensure anterior re-
traction , the archwire must be bent tightly against
the distal of the second molar tube . This should
all occur with no anchorage loss in the buccal Figure 47. Placement of (A) .014 superelastic NiTi , (8)
segments . Retroinclination also is easier with the .020 superelastic NiTi, (C) .018 x .025 superelastic
use of round wires and the small amount of force NiTi and (O) .021 x -.025 superelastic NiTi .
needed to achieve it.
When alignment has been accomplished,
be achieved from back to front with minimum an-
extraction spaces will have been reduced in a
chorage mechanics.
direct proportion to the initial crowding and the
anterior retraction achieved. At this point, the inci- Space closure is done in most cases with a
sors often are retruded into the position planned DKL archwire retracting the six anterior teeth to-
in the VTO. The remaining space closure will gether as a unit and/or protracting posterior teeth

373
 Treatment Mechanics
as dictated by VTO planning (Fig. 48 ). This sys-
tem of space closure without friction is the most
efficient method for retracting protruded incisors
and presents many advantages over a system of
space closure using friction or sliding mechanics.
When teeth slide on an archwire , in addition to the
force needed for the tooth movement, it is neces-
sary also to apply force to overcome frictional re-
sistance .30 The use of unnecessarily high torces to
move teeth , creates anchorage control problems .
Figure 48 .. 019 x .025 double keyhole-loop archwire
used to clase mandibular spaces. Typically, mandibu-
lar arch treatment progresses ahead of maxillary arch
treatment.
According to Kusy and colleagues , for .022
brackets ligated with a metallic ligature to a .019
x .025 stainless steel wire , the minimum frictional
resistance to sliding a single bracket is about 100
gm .46 Therefore, in addition to the 100 gm neces-
sary to move a canine distally along an archwire ,
an additional 100 gm is needed to ove reo me fric-
tion . As a result, the total force needed to slide the
tooth along the archwire will be two times greater
than that which is expected .
According to Proffit, with respect to orth-
odontic anchorage , the problem created by fric-
tion is not only its presence and the difficulty in
determining the magnitude of force required to
overcome the friction , but that the force needed to
overcome the friction will be close to the amount
needed to cause the movement of anchorage
teeth .30 In order to obtain differential tooth move-
ment, the coefficient between the root area in the
anchorage unit and in the movement unit should
374
be a minimum of 2:1 without friction and 4:1 with
friction . Any less force will produce someth ing
similar to a reciproca! movement of anchorage
and will result in unfavorable tooth movement.
Differential Anchorage Mechanics. To attain
treatment goals, it is essential that during space
closure , the clinician be able to depend on treat-
ment mechanics to control the amount of anteri-
or retraction or bucea! segment mesialization as
planned. The VTO allows the clinician to visualize
this in a clear way and to determine the proportion
of molar mesialization/incisor retraction needed .
The appropriate mechanics can then be chosen .
Using the VTO to preplan mechanics is an invalu-
able step in achieving excellent treatment out-
comes (see Chapter 7) .
Minimum anchorage is required when the
relation between molar mesialization and incisor
retraction is approximately 75% :25%. Moderate
anchorage is required when the relationship is
approximately 50% :50% . Maximum anchorage is
required when the relationship is 25% :75%.
Resistance to mesial movement of the buc-
ea! segments depends on facial biotype , whether
mesial movement is required in the mandible or in
the maxilla , the root area of involved teeth , tooth
position (vertical , mesial or distal inclination), and
how the movement will be carried out (by tipping
or body movement, with or without friction) . As a
means of enhancing anchorage in the bucea! seg-
ments, it is common to use auxiliary elements such
as extraoral forces or intermaxillary elastics (which
depend on patient compliance), transpalatal bars ,
lingual arches or mini implants.
There also is resistance to the retraction
movement in the anterior segment, the amount
of which depends on the same factors listed for
the bucea! segments . The concept of differential
anchorage depends on increasing or decreasing
the anchorage value of the anterior or bucea! seg-
ments as is required .
The most logical approach would be to in-
crease root area (i.e ., the number of teeth) in the
segment that needs to have anchorage increased,
and decrease root area of the tooth or teeth that
need to be moved . In addition , should the sec-
ond molar be included or not in the posterior an-

Figure 49. Root area (mm 2 ) .
chorage unit? Should the canines be distalized
first and then the incisors retracted , which would
avoid the retraction of the six anterior teeth simul-
taneously? In the case of minimum anchorage ,
should second premolars be extracted and the
eight teeth in the anterior segment used to mesial-
ize the first and second molars?
When reviewing tooth root area (Fig . 49), it is
apparent that the root area in the bucea! segments
is almost twice that of the six anterior teeth . lf this is
so , why is posterior anchorage lost? One reason
may be related to the amount of force applied; e.g.,
using light forces will keep the force level below
the amount of force needed to move the posterior
anchorage segment. The use of heavy torces will
produce movement in both segments, i.e., in the
anchorage segment and in the segment in which
movement is desired. In the no-friction space clo-
sure techn ique, the amount of force generated de-
pends on severa! factors such as the type of wire
(e.g., stainless steel closing archwires vs. blue
elgiloy or Beta titanium), the characteristics of the
wire , the amount of activation, closing loop design,
and the amount of wire used in the loop.
Another factor to consider, due to its influence
on anchorage value, is tooth position. lt is well
known that mesial inclination of molars and pre-
molars decreases their resistance to mesial move-
ment and that uprighting them or better yet, distal
inclination , increases their resistance consider-
ably. This last factor, introduced by Tweed in his
treatment mechanics for anchorage preparation , is
probably the most used in orthodontic therapy, and
Aya/a
it is efficiently and predictably achieved with the
distal inclination values incorporated in the goal-
directed prescription for molars and premolars.
Anchorage preparation begins with the first
archwires and will increase with progression in
wire diameter. On the other hand, an increased
labial inclination of the incisors and/or mesial incli-
nation of canine roots (factors that must be consid-
ered in the case of simultaneous retraction of the
six anterior teeth) denote a significant increase in
anterior anchorage and may cause complete me-
sialization or lose of posterior anchorage if bodily
movement is ach ieved using rectangular closing
archwires.
Roth and Williams advise that an inclination
of 9r or more of the mandibular incisors to the
mandibular plane creates a situation in which it is
possible to lose posterior anchorage easily, par-
ticularly if rectangular closing archwires are used .
lf the mandibular incisors have a 93 ° buccolingual
inclination or less, posterior anchorage is always
greater than anterior anchorage , and the move-
ment will be almost exclusively anterior retraction.
The same considerations should be applied to
tooth movement in the maxilla. 3
In cases of minimum anchorage , the torque
should be increased in the incisors in arder to in-
crease anterior anchorage. In effect, the torque
to the incisors, especially the maxillary incisors
due to their normal torque values, not only in-
creases anterior anchorage, it also can "burn" an-
chorage when mesializing bucea! segments. In
the goal-directed prescription , the torque values
375
Treatment Mechanics
for the maxillary incisor are increased 5o to achieve
an overcorrected tooth position. This may cause
a posterior loss of anchorage if rectangular arch-
wires (especially .021 x .025 archwires) are used.
This increase in anterior anchorage is one of the
reasons that .021 x .025 archwires are used in
minimum anchorage cases .
The above emphasizes the need to consider
using auxiliary elements to enhance posterior an-
chorage when space closure is begun with .019 x
.025 wires and especially if begun with .021 x .025
wires, if preserving posterior anchorage is impor-
tant. For this reason , Roth and Williams also rec-
ommend , that during Stage 111 treatment (spaces
have been closed , the molars are in Class 1, and
the correct OB/OJ relation has been established) ,
short Class 11 elastics 1/8 heavy be used to over-
correct the tooth positions attained with .021 x
.025 archwires , so that the achieved Class rela-
1
tionship is not lost.J
One other consideration in anchorage plan-
ning is the specific kind of dental movement.
Bodily movements normally performed using .019
x .025 SS wires require twice the force needed
for tipping movements with smaller diameter wires
(Fig . 50) . In other words , the larger the wire di-
ameter, the greater the anchorage in the teeth
that are moved ; the smaller the wire diameters,
the less the effective tooth anchorage. This is one
of the principies of differential mechanics applied
to extraction site closure : use a rectangular clos-
ing archwire of a larger size (e.g., .021 x .025 stain-
less steel) in the area that needs more anchorage
and reduce its size in the area that is being moved .
To reduce the size of the wire , an electrolytic bath
Figure 50. Tipping movement (/eft) and bodily move-
ment (right) .
376
is used to provide a smooth surface to decrease
friction . This reduction also can be accomplished
with a green stone by rounding the wire edges ,
followed by polishing with a rubber disc.
In a case with minimum anchorage , the se-
lected archwire would be a .021 x .025 DKL, the
full size of which is used in the incisor and cuspid
segment to provide more anterior anchorage. The
wire is reduced in the molar and premolar area
that is to be mesialized. The anterior anchorage
is enhanced with incisor torque and mesial incli-
nation of the canine . Posterior anchorage is mini-
mized by the wire reduction . When the wire is acti-
vated , the "prepared" anterior segment will be an
effective anchor unit that can resist mesialization
forces to the posterior segment.
The efficiency of these mechanics is increased
if the premolars are added to the anterior segment
(first premolar in the case of second premolar ex-
traction) . Also , the activation of the closing arch-
wire or coil spring is made from the first molar
(Fig. 51). In cases treated with first premolar ex-
tractions , the second premolars are mesialized
in arder to obtain an anterior anchorage group of
eight teeth .
lf, despite the efforts taken in the mandible,
the anterior segment tends to retract more than
necessary, anchorage to this segment is increased
by placing short Class 11 elastics 1/8 heavy from
the maxillary cuspid to the mandibular premolar.
This modality of minimum anchorage is probably
the most commonly used because at the end of
the alignment and leveling stage , the desired in-
Figure 51 . Minimum anchorage mechanics with .021 x
.025 SS double keyhole loop, reduced posteriorly, and
medium superelastic NiTi closed coil spring .

Figure 52. Pretreatment intraoral photographs.
cisor retraction typically has occurred already.
Therefore, the remaining spaces should be closed
from back to front. Using a lingual bar cemented
from cuspid to cuspid to form an anchorage block
that resists lingual incisor movement is a practica!
tip for cases such as this, as it reduces the need
for patient cooperation (Fig. 58) . All of these pre-
cautions can be taken to avoid incisor retraction
in cases in which lip position is correct. Figures
52-58 show an extraction case in Stages 1 and 11 .
T-loop Beta titanium and SS double keyhole-loop
archwires were used for space closure.
Obviously, activation from the second mo-
lar will increase posterior anchorage. In maximum
anchorage mechanics, the selected archwire also
should be a .021 x .025, using the full size archwire
in the bucea! segments and rounding it in the anteri-
or segment from cuspid to cuspid . A retro-inclination
of the anterior segment will occur sin ce this requires
less force than the bodily movement of the bucea!
segments. Bodily movement of the bucea! seg-
ments would require a force threshold that is twice
that which is necessary for anterior retraction . Ac-
tivation in these cases is from the second molar.
Aya/a
Summary
Listed below are the steps that can be used
to increase or decrease the anchorage of each
segment in differential anchorage mechanics:
l . lncrease or decrease the root area (number
of teeth)
2. Alter the type of movement used (bodily or tip-
ping) by reducing or maintaining the size of
the archwire
3. Actívate the double keyhole loop with a liga-
ture from the second premolar, first molar, or
second molar according to the predetermined
anchorage requirements
4. Use auxiliary elements such as intermaxillary
elastics, transpalatal bars, lingual arches , a
Nance appliance , or mini-implants to enhance
anchorage.
Based on these principies, Figures 59-61 illustrate
the use of closing mechanics with DKL archwires
in minimum , medium and maximum anchorage
cases .
The double keyhole-loop wire is activated ev-
ery six weeks by opening each key 1 mm . Each ac-
tivation will produce a space closure of 2 mm, with
the space usually being completely closed within
three to five months. The reason for the six-week
wait between activations is to allow the teeth time
to recover their vertical position . Because space
closure is achieved with .019 x .025 or .021 x .025
reduced wires, tooth translation is accomplished
first with a tipping movement that is followed by
an uprighting movement. With the tipping move-
ment, the Curve of Spee tends to increase; it then
recovers during the uprighting movement. lf the
activation is too frequent and the teeth are not al-
lowed to upright completely, the Curve of Spee
will be excessive at the end of closure. This is dif-
ficult and time consuming to correct, and it burns
anchorage. Activation is postponed if the cuspid
crown is mesial to or directly over its root; in other
words , the cuspid root should remain distal to its
crown . Correction of distal crown inclination of the
cuspid is one of the activities that can burn a lot of
anchorage . Not allowing time for teeth to recover
their vertical position during space closure is not
recommended ; it may be said "that in space clo-
sure, the best way to go fast is to go slow. "
377
Treatment Mechanics

Figure 53 . Patient with .020 superelastic NiTiarchwires .

Figure 54 . Patient with .018 x .025 archwires.

Figure 55. Patient with maxillary and mandibi..Jiar T-loop Beta Titanium archwires .

Figure 56. Patient with maxillary T-loop Beta Titanium and mandibular .019 x .025 double keyhole-loop archwires.

Figure 57. Patient with maxillary T-loop Beta Titanium and mandibular .019 x .025 stainless steel archwires.

Figure 58. lntraoral photographs

taken before (left) and after (ríght)
closing the spaces.

378
 Aya/a

Figure 59. Space closure in a mínimum anchorage case using DKL archwires.

Figure 60. Space closure in a medium anchorage case using DKL archwires.

When space closure has been completed ,
Roth and Williams recommend that the DKL wire
remain activated for an additional period of time
(two to three months) until all the hard and soft
tissue that has been compressed into the extrac-
tion space has histologically remodeled .3 Another
choice would be to go to a rectangular straight
wire and use elastic chains from the second molar
to the canine to keep pressure on the extraction
site. In some cases , it may be necessary to have a
periodontist perform gingival surgery to prevent a
space from reopening .
The most often used archwires after space
closure are .018 x .025 superelastic NiTi or .019 x
.025 stainless steel. Once engaged and leveled , it
is necessary to upright the molars and premolars
and complete mesial inclination of the canine using
.021 x .025 stainless steel wires to prevent space
reopening . Mesially inclined molars and premo-
lars tend to promete space reopening.

379
Treatment Mechanics

tial anchorage mechanics , this modal ity is used in

41Lllf 41Lttt cases with minimum and med ium anchorage . Fig-
ure 62 (posted arches with coil and medium an-
chorage) illustrates the sliding mechanics used for

l\,ww ~·w
space closure in these types of anchorage cases .
In minimum anchorage cases , posterior teeth
are moved mesially one at a time against an ante-
rior anchorage unit of at least six, or ideally eight,

41MB I/4JHB
teeth . For this , a .021 x .025 DKL archwire is used
with reduction in the posterior segments , and the
coil is placed on the first molar hook and ligated to
the first or second archwire keyhole loop until an

- ~"
Figure 61 . Space closure in a maxi mum anchorage
case using DKL archwires.
Sliding or Friction C/osure
Space closure also can be accomplished by
sliding the teeth on an archwire . Todo this , a .019
x .025 archwire with crimpable hooks, a .019 x
.025 posted archwire , ora .019 x .025 or .021 x
.025 DKL (depending on the needed anchorage)
may be used . Asan active element , elastics, elas-
tic chains or closed coils of any kind may be used .
The preference is to use 4 mm long superelas-
tic Ni Ti el o sed coils of medium force ( 150 gm) or
heavy force (200 gm) that have a ring in each end
to facilitate use. Based on the concept of differen-
activation of 14 to 16 mm of the coil is obtained .
This achieves the necessary force to mesialize
molars due to the superelastic NiTi characteris-
tic that provides a constant force during space
closure. By ligating the coil spring in the keyhole
loop , torces are directed in a more apical direc-
tion with the purpose of approaching the center of
resistance of the anterior teeth , producing a bodily
movement that, in sum , increases the anchorage
of the anterior segment (Figs . 59 and 81 ).
In minimum anchorage cases , the preference
is to create an anterior anchorage unit of eight
teeth including premolars (Figs. 63-82). In the case
of first premolar extractions , the second premolars
are mesialized first to incorporate them into the an-
terior segment. Again , the use of a cemented lin-
gual bar from cuspid to cuspid or miniscrews can
be helpful in such a case (Fig. 58) .

1J A&M !1 ~~M /J AlM

~-y éfl{ ~~ 1\l\("
Figure 62 . Sliding mechan-
ics using .021 x .025 SS
archwires reduced posteri-
orly and medium superelas-

~lJ ~(IM ...,.-.,'-'~

~.d(~ M .i1~1J.M
tic NiTi closed coil springs in
medium anchorage space
closure.
. , .. . , ,_, . -·~
. . .# ...
--..,"'"""·

~-

'1 ,lft.. _ . ,~ ~- __

·~,lft..
. ,-,..

'<'l"..
~- __ . ,~

380
 Aya/a

Figure 63 . Patient A pretreatment intraoral photographs .

Figure 64. Patient A with .019 x .025 stainless steel archwires. In the maxilla , the second bicuspids were mesi-
ally moved with medium superelastic NiTi open coil springs.

Figure 65. Patient A with .019 x .025 stainless steel archwires with medium superelastic Ni Ti closed coil springs
to move the maxillary first molars mesially.

Figure 66. Patient A with the same archwires as in Figure 64 but with the extraction spaces closed .

Figure 67. Patient A with .021 x .025 stainless steel maxillary and .019 x .025 stainless steel mandibular archwires.

Figure 68 . Patient A with maxillary and mandibular .019 x .025 braided archwires.

381
Treatment Mechanics

Figure 69. Patient A: Comparison of pretreatment and post-treatment intraoral photographs.

Figure 70. Patient B pretreatment intraoral photographs.

Figure 71 . Patient B with a maxillary .014 superelastic NiTi archwire.

Figure 72. Patient B with maxillary and mandibular .018 x .025 superelastic NiTi archwires .

Figure 73. Patient B with maxillary .018 x .025 superelastic NiTi archwire and man-
dibular .019 x .025 stainless steel archwire and medium superelastic NiTi closed
coil spring .

382
 Aya/a

Figure 74. Patient B with maxillary and mandibular .019 x .025 stainless steel archwires finalizing space closure.

Figure 75. Patient B consolidating space closure.

Figure 76. Patient B with .021 x .025 steel archwires.

Figure 77. Patient B with maxillary and mandibular .019 x .025 braided archwires.

Figure 78 . Patient C pretreatment intraoral photographs.

383
Treatment Mechanics

Figure 79. Patient e with maxillary and mandibular .014 superelastic NiTi archwires.

Figure 80 . Patient e with maxillary and mandibular .020 superelastic NiTi archwires.

Figure 81 . Patient e with maxillary .019 x .025 stainless steel archwires and mandibular .019 x .025 double key-
hole-loop archwires with medium superelastic NiTi closed coil springs.

Figure 82 . Patient e post-treatment intraoral photographs .

Figure 83 . Patient D pretreatment intraoral photographs. This patient was a periodontal case.

Figure 84 . Patient D: maxillary and mand ibular .019 x .025 posted archwires/med ium superelastic NiTi closed
coil springs.

384

Figure 85. Patient D with same archwires as seen in Figure 84 , but with spaces closed.
Figure 86 . Patient D with maxillary and mandibular .019 x .025 braided archwires.
In cases in which the treatment plan calls
for a medium anchorage space closure (i.e. , an
anterior segment retraction and advancement of
buccal segments in a 50 :50 or 60 :40 relation) ,
the force is directed from the first molar hook
to the anterior segment, but this time at crown
level to facilitate more lingual crown movement.
This can be done with .019 x .025 posted arch-
wires directing the force from the molar hooks
to the hooks between the canine and the lat-
eral incisor or directly to the cuspid bracket
hooks. The force applied should be 150 gm to
180 gm on each side , using medium or heavy
force superelastic closed coils . The clinician will
be able to increase or decrease segment move-
ment by reducing the archwire or maintaining
its rectangular section , or by activating from
the first molar or the second molar. Figures 83
through 86 illustrate a medium anchorage case .
The third stage in extraction cases is the
same as that in nonextraction cases , except that
the elastic chains remain in place to consolidate
the space closure.
ACCESSORY ELEMENTS.
As in most orthodontic techniques , goal-di-
rected treatment mechanics also uses some ac-
cessory elements such as active elements for
tooth movement or elements that reinforce an-
chorage .
lntermaxillary Elastics
lntermaxillary elastics are used mainly:
Aya/a
• In the correction of the dental relationship of
Class 11 or Class 111
• In correction of dentoalveolar crossbites of one
or more teeth
• To clase lateral open bites in the buccal seg-
ments, or correct the Curve of Spee
• To achieve an adequate intercuspation using
vertical torces once a Class 1 relation is ob-
tained
• As an active element to retract the maxillary in-
cisors
• As an anchorage enhancement element
The use of elastics in the goal-directed ph i-
losophy has specific considerations and indica-
tions that are related closely to the orthodontic
goals, especially the functional occlusion goal.
As previously stated , one of the things to avoid
during orthodontic movement is any extrusive
movement, especially in the molar area , as this
can cause condylar distraction. An increase in
the vertical dimension at the dentoalveolar level ,
especially in the posterior segment, that is not
equaled or exceeded by mandibular ramus growth
may cause an open bite or a condylar distraction
or both . In the non-growing patient, however, the
"compensatory" mechanism of mandibular ramus
growth does not exist. Therefore, the precautions
taken to ensure that an increase in the dentoal-
veolar vertical dimension does not occur should
be even greater for these patients (see Chapter
1, Fu/crum) .
The response to intermaxillary elastic me-
chanics is different in the different skeletal biotypes.
385
Treatment Mechanics

Muscular force in a brachyfacial patient makes vector. Directing the force to the mandibular pre-
the extrusion of the bucea! segments more dif- molar area helps to correct the Curve of Spee,
ficult, and in most cases if it occurs , it will re- which would not happen or would be more difficult
lapse. In this facial biotype , good mandibular if the torces are directed to the molar area .
ramus growth is common. Dolichofacial patients
In non-compliant patients for whom maxillary
present a greater problem , especially severe
anterior retraction is needed , one of the ways to
dolichofacial patients for whom incorrectly ap-
obtain the necessary retraction force is with Class
plied elastics will produce undesired effects.
11 elastics placed from the mandibular premo-
The use of Class 11 elastics can also produce lar area to the first or second key of the double
an extrusion of the anterior segment with an in- keyhole-loop archwire. This is especially useful
crease in the gingival and incisor exposure , es- in critica! anchorage cases and, in general , when
pecially when use is prolonged and/or if flexible the amount of retraction required is not great. In
archwires are in place . Prolonged use also could arder to do this , the lateral segments of the DKL
produce an increase in the lower facial third verti- archwire must be reduced to facilitate the arch
cal dimension which may compromise lip closure sliding distally or a round .020 DKL can be used
and/or any of the treatment goals being sought. when retroinclination of incisors is necessary or
possible. Thus , the worst thing that can happen if
In general , intermaxillary elastic use should
the patient does not wear the elastics is that the
be limited as much as possible , although avoiding
case will not progress. At least there will be no
them completely is not always possible . In spite
loss of posterior anchorage , which is especially
of the fact that using long elastics (example Class
important if anchorage is a critica! factor. lt is im-
11 elastics from the maxillary cuspid to the man-
portant also to control very closely the amount of
dibular second molar) produces a more horizon-
time that elastics are used against the maxillary
tal force vector, their use is not recommended for
canines , especially with respect to vertical forces ,
functional occlusion reasons . The most frequent
since the 1 mm overjet between canines that is
centric and eccentric functional interferences are
necessary for eccentric mandibular movements
at the second molars; therefore , any extrusion of
could be lost.
these teeth should routinely be avoided .
Elastics also can be used to increase or de-
The configuration most commonly used is
crease anchorage in the bucea! segments. One
strong short elastics (1/8" or 3 mm and 6 oz) that,
way to increase anchorage in extraction cases
in a Class 11 nonextraction case , are placed from
in the maxillary posterior segments is by using
the maxillary canine to the first or second man-
Class 11 elastics between the mandibular first mo-
dibular premolar. In extraction cases , the elastics
lar and the maxillary second or first premolar. lt
are placed from the maxillary cuspid to the man-
is essential to use rigid archwires such as .019 x
dibular second premolar or the first molar. In an
.025 or, ideally, .021 x .025, especially when no
attempt to avoid an unfavorable force vector to
mesialization of the mandibular arch is desired . lt
the first molar, it is recommended that the elastic
is important to consider for both Class 11 and Class
be placed from the maxillary lateral to the second
111 elastics, the angulation of the incisors as well
mandibular premolar using a Kobayashi hook or
as their position in the mandibular symphysis or
a stop mesial to the maxillary lateral incisor. In
palatal bone . The relation of the roots to the cor-
cases where a DKL is being used in the maxil-
tical plates is the most important limitation when
lary arch , the elastics should be placed from the
considering incisor movement. Excessive move-
mesial key of this archwire. An attempt should be
ment, which can cause periodontal injury and of-
made to avoid applying force to the first maxillary
ten produces tooth position instability, certainly is
or mandibular molars. Beca use of their shortness,
not desired .
it is necessary to use strong elastics (generally
1/8 heavy) that can hold the teeth in occlusion and As was discussed earlier in this chapter, one
thus reduce the vertical component of the force of the important features of the goal-directed pre-

386

scription is its ability to provide excellent anchor-
age , especially in the mandible.2 Therefore , it gen-
erally is not necessary to use Class 111 elastics for
retraction of the anterior mandibular segment.
lntermaxillary elastics also are used as an
auxiliary element to achieve adequate intercuspa-
tion. Configured as a square oras a triangle (with
the apex ofthe triangle on the tooth requiring more
movement) or Class 11 or Class 111 vector (based
on the original malocclusion), these elastics are
used in the final stage of treatment with .019 x
.025 or .021 x .025 braided rectangular archwires
placed in both maxillary and mandibular arches or
in the arch that requires the most movement. The
flexibility of the wires allows small vertical tooth
movements in order to achieve the correct inter-
cuspation (Fig. 15). lt should be noted that this is
only possible and recommended when the sepa-
ration between the opposite teeth is 1 mm or less.
Greater discrepancies in the occlusion between
antagonistic teeth should be corrected with bends
in the wire or ideally by repositioning the neces-
sary brackets. In this stage, special attention is
paid to directing the cusp into the corresponding
fossae or marginal ridge to avoid cusp-to-incline
contacts that prevent the "closure" of the mandi-
ble to an occlusion with proper vertical dimension
and anterior guidance.
Criss-Cross Elastics
Usually, criss-cross elastics are placed be-
tween buccal attachments on mandibular bicus-
pids and molars and lingual attachments on max-
illary bicuspids and molars. While cross elastics
often are used for the correction of lateral cross
bites of one or more teeth , their use is restricted
(especially when the involved teeth are second
molars) to avoid any extrusion that may cause a
molar fulcrum. lt is important to determine which
of the involved teeth requires the greatest move-
ment, so that a flexible archwire is used in that
arch and a rigid archwire is placed in the opposite
arch where limitation or avoidance of transverse
movement is desired . In addition , using transpala-
tal bars in the maxillary first or second molars, or
lingual arches in the mandible or just plain wire
bends provides additional stability. lt also is impor-
tant to determine if the problem is dentoalveolar
or skeletal , since all the maneuvers described are
Aya/a
indicated only in dentoalveolar transverse altera-
tions and those where the apical base allows it.
During the final stage and final seating of the
occlusion , some publications recommend that the
wires be taken off in the buccal segments and "up
and down" elastics added , leaving an arch seg-
ment in the maxillary and mandibular incisors. lt is
important to remember, however, that the elastic
force is applied on the buccal side of the teeth
and the resulting force vector, with respect to the
center of resistance of these teeth , produces a
greater movement of the buccal cusp than the
lingual cusp, especially when these teeth do not
have an archwire to control their movement. This
greatly reduces the possibility of establishing the
tight cusp-to-fossa or cusp-to-marginal ridge rela-
tionships that are so important for a healthy and
stable occlusion.
The goal is to achieve a correct intercuspa-
tion and have all the necessary ingredients of an
ideal occlusion in place while the patient is still
wearing the appliances. What is the use of argu-
ing about torque and/or inclination if these ideal
positions are lost at the end of treatment? When
appliances are removed and the teeth settle, the
spontaneous settling with no controls likely will re-
sult in centric cusps contacting opposing inclines,
which in turn produces a mandibular shift and ,
with it, a condylar distraction. Roth used to say
that when the teeth are allowed to settle by them-
selves , the condylar distraction generally is great-
er, and though this is difficult to see clinically, it
becomes quite evident when an accurate mount-
ing in centric relation is done or, more probably,
with ultimate relapse , wear, and muscular and/or
joint dysfunction .1·3
lt is very common to consider closing anteri-
or open bites by using vertical elastics of different
configurations in the incisor area. The goal-direct-
ed philosophy does not recommended this due
to the condylar distraction that this may produce .
This is one of many therapeutic choices that is
designed to solve the dental problem , but it does
not address the real etiology. In general , anterior
open bites can be produced by:
1. A lack of vertical dentoalveolar development
in the maxillary and/or mand ibular incisor area
produced by tongue thrusting or any other ha bit
387
Treatment Mechanics
2. An increased vertical dentoalveolar growth in
the maxillary or mandibular molar area
3. Premature cusp-to-cusp contacts or cusp-to-
inclines in CR
4. A true skeletal open bite
5. Any combination of the above
With the exception of thrusting habit cases in
which therapy is directed towards the elimina-
tion of the habit and the leveling of the arches ,
vertical control is used to restrict vertical den-
toalveolar growth and/or intrude maxillary and
mandibular buccal segments with miniscrews,
transpalatal bars , centric bite blocks or high-pull
headgear, depending on the problem . Diagnos-
tically these patients generally present with in-
creased lower facial third , lip closure is deficient
and facial aesthetics are compromised. These
factors are due to a clockwise mandibular ro-
tation . For these patients, vertical control is of
great benefit. Certainly there are cases in which
the magnitude of the problems are too great for
orthopedic possibilities and orthognathic sur-
gery is the only option . This occurs more fre-
quently in cases with a significant skeletal com-
ponent such as patients with a short mandibu-
lar ramus with little growth potential , an obtuse
gonial angle and/or vertical maxillary excess .
Transpalatal Bar
The transpalatal bar is one of the accessory
elements frequently used in goal-directed treat-
ment mechanics, often on the first and second
maxillary molars, due to its versatility and efficacy
(Fig . 87). This therapeutic element allows the or-
thodontist to :
1. Vertically control the position of the maxillary
first and second molars
2. Help maxillary and mandibular arch coordina-
tion by transverse expansion or compression
3. Use the element in torque and molar rotation
Except for vertical control , all other actions are
achievable with the archwires and the fea tu res built
into the brackets. Nevertheless, transpalatal bars
388
Figure 87 . Transpalatal bar with acrylic button.
allow these movements to occur more efficiently.
The importance of the transpalatal bars
as part of the treatment mechanics is evident
during treatment planning with models accurately
mounted on an articulator. The most common
finding is that the premature contacts are on the
first and especially the second molars. This often
is due to a lack of correct cusp-to-fossa contact
or cusp-to-opposite marginal ridge relationship ,
which props the mandible open and increases
the vertical dimension . In arder to improve its ef-
ficiency, the transpalatal bar is placed 6 to 8 mm
away from the hard palate with an acrylic button
as wide as possible to enhance its vertical ef-
fect. The patient is instructed to push the tongue
against the button during swallowing .
The most appropriate time for vertical control
is during the early mixed dentition . At this time ,
the vertical control of the first permanent molars
and the selective grinding of deciduous molars al-
low the achievement of an effect that becomes
more difficult to obtain once the premolars have
erupted .
Centric Bite Block
The centric bite block is a maxillary or
mandibular orthopedic appliance that covers
the lateral segments buccally, lingually and oc-
clusally. lt is designed to have multiple contacts
on the antagonistic teeth that are bilateral and
of equal intensity. (Fig . 88). Centric bite blocks
that are used in the early treatment of skeletal

open bite or vertical Class 11 cases produce a
forward and upward (counterclockwise) man-
dibular rotation by transmitting the mastica-
tory muscle torces to the buccal dentoalveolar
regions and reducing their vertical growth. ln-
creasing the vertical dimension by this means
produces skeletal changes not only in the dento-
alveolar region , but in other areas of the craniofa-
cial complex .34 Passive posterior bite blocks are
effective in the treatment of skeletal open bite and
in producing overbite as a result of the upward
and forward rotation of the mandible and the ver-
tical development of the lower anterior dentoalve-
olar region. 34 ·39 ·42 ·43 Altuna and Woodside conclud-
ed that passive posterior bite blocks cause the
mandible to develop in a more horizontal direc-
tion .35 lscan found that the bite block caused an
increase in the SNB angle , while the lower tace
height and mandibular plane angle decreased .34
lscan 's work corroborated Dellinger's as they
both found a decrease in the lower posterior den-
toalveolar height in treatment groups.34.43
The bite block not only inhibits vertical
growth , but eventually intrudes posterior teeth . lt
is more versatile than the transpalatal bar, as it af-
fects both mandibular and maxillary teeth . Altuna ,
Weislander, McNamara and others have reported
on using the appliance in a manner similar to that
described above , i.e. , basically asan acrylic ap-
pliance that covers the occlusal surface of molars
and premolars or deciduous molars with the inten-
tion of controlling vertical development. 35-41 This
appliance , fixed or removable , allows the anterior
segment teeth to remain free in cases where their
passive eruption would help correct the overbite .
This would not be indicated for patients who have
a normal or increased incisor exposure.
The mechan ism responsible for the bite-
block affect is elevator muscle force. Separate
studies by McNamara , Woods and Nanda and
Sander and Weinreich show that isolated contact
of posterior teeth produces an increase in electro-
myographic activity (or elevator muscle hyperac-
tivity) that is responsible for this appliance 's intru-
sive capacity.J7A4.4 5 In another study, Kuster and
lngervall found that the bite force and the activity
of the masseter and the anterior temporal mus-
Aya/a
eles increased during early stages of the treat-
ment; they also found an increase in mandibular
prognathism when the bite block was used. Stud-
ies also indicate that increasing the height of the
posterior bite block further increases the clock-
wise mandibular rotation , the greatest intrusive ef-
fect being achieved with bite blocks 8 mm high .33-
34·37 lscan 's study showed that the downward and
backward mandibular rotation continued in his
control group increasing the lower facial height
significantly, whereas in patients treated using
bite blocks , the skeletal open bite was corrected
and the mandible rotated upward and forward. 34
Other studies show that isolated contact of
anterior teeth produces a muscle pacification ,
and decreased electromyographic activity. This
is one of the principies of anterior guidance (see
Chapter One ).
Guided by concepts of function and gnathol-
ogy, the bite plane is adjusted the same way as
is done when using a centric relation splint or a
mandibular repositioning splint. The goal is to
seat the condyles in centric relation . This is done
in an attempt to avoid a fulcrum (see Chapter
One) that may cause an apparent bite correc-
tion through condylar distraction or an interna!
derangement rather than actually achieving the
vertical change. For this reason , it is called a cen-
tric bite block. In the goal-directed design , the bite
block can be used in the mandible or the max-
illa , with the thickness of the intermaxillary acrylic
varying from 2 to 3 mm. In cases in which a cor-
rection of torque or upper molar rotation is neces-
sary, a transpalatal bar can be used in the maxilla
and a centric bite block in the mandible.
In order to adjust the occlusion on the ap-
pliance , the centric bite block can be removed at
the beginning of treatment to allow the mandibu-
lar position to stabilize . Whether to continue with
a removable centric bite block or switch to a fixed
one will depend on patient compliance. Experi-
ence has shown that using this appliance as a
removable one is preferable , as it enables the or-
thodontist to control the occlusal contacts of the
opposite teeth and to actívate a transpalatal bar
(Figs . 88-89).
389
Treatment Mechanics
Figure 88 . Vertical control with centric bite block.
Figure 89. Patient with centric bite block one year later.
One of the benefits of this appliance is that
it provides an increase in anchorage for the teeth
on which it is placed, especially when it is "fixed ."
lt also has proven to be an excellent anchorage
medium for the traction of included teeth.
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