Methods of Ligation
Metal ligationBy Prof Dr
In orthodontics ligation method refers to themeans by which an archwire is held inside thebracket Conventionally elastic or metallic tieswere used to hold the archwire in place howevermore recently ligating methods have been designedand built directly into brackets
Currently the three most common ligation systems are active- and passive self ligation and conventional elastic ligation
Research has shown that different ligation types produce different force and moment systems along the orthodontic arch specifically passive self-ligation has been found to decrease the forces and moments produced when compared to elastic ligation which may lead to increased patient comfort
This is because elastic ligation actively holds
The wire in place against the bracket whereas passive ligation simply guides the wire while leaving room for movement
Variable Force Orthodontics Delta Force Bracket Features The Delta Force Bracket ndash A Change for the Better The Delta Force Bracket System incorporates an advanced design that allows you to control the friction between the archwire bracket and ligatures
The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results
Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces
Delta Force Ligation Options
Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment
Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control
Minimum Force Maximum Force
Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire
Minimum Force Maximum Force
Medium Force
Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation
Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
In orthodontics ligation method refers to themeans by which an archwire is held inside thebracket Conventionally elastic or metallic tieswere used to hold the archwire in place howevermore recently ligating methods have been designedand built directly into brackets
Currently the three most common ligation systems are active- and passive self ligation and conventional elastic ligation
Research has shown that different ligation types produce different force and moment systems along the orthodontic arch specifically passive self-ligation has been found to decrease the forces and moments produced when compared to elastic ligation which may lead to increased patient comfort
This is because elastic ligation actively holds
The wire in place against the bracket whereas passive ligation simply guides the wire while leaving room for movement
Variable Force Orthodontics Delta Force Bracket Features The Delta Force Bracket ndash A Change for the Better The Delta Force Bracket System incorporates an advanced design that allows you to control the friction between the archwire bracket and ligatures
The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results
Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces
Delta Force Ligation Options
Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment
Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control
Minimum Force Maximum Force
Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire
Minimum Force Maximum Force
Medium Force
Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation
Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Currently the three most common ligation systems are active- and passive self ligation and conventional elastic ligation
Research has shown that different ligation types produce different force and moment systems along the orthodontic arch specifically passive self-ligation has been found to decrease the forces and moments produced when compared to elastic ligation which may lead to increased patient comfort
This is because elastic ligation actively holds
The wire in place against the bracket whereas passive ligation simply guides the wire while leaving room for movement
Variable Force Orthodontics Delta Force Bracket Features The Delta Force Bracket ndash A Change for the Better The Delta Force Bracket System incorporates an advanced design that allows you to control the friction between the archwire bracket and ligatures
The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results
Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces
Delta Force Ligation Options
Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment
Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control
Minimum Force Maximum Force
Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire
Minimum Force Maximum Force
Medium Force
Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation
Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Research has shown that different ligation types produce different force and moment systems along the orthodontic arch specifically passive self-ligation has been found to decrease the forces and moments produced when compared to elastic ligation which may lead to increased patient comfort
This is because elastic ligation actively holds
The wire in place against the bracket whereas passive ligation simply guides the wire while leaving room for movement
Variable Force Orthodontics Delta Force Bracket Features The Delta Force Bracket ndash A Change for the Better The Delta Force Bracket System incorporates an advanced design that allows you to control the friction between the archwire bracket and ligatures
The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results
Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces
Delta Force Ligation Options
Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment
Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control
Minimum Force Maximum Force
Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire
Minimum Force Maximum Force
Medium Force
Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation
Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
This is because elastic ligation actively holds
The wire in place against the bracket whereas passive ligation simply guides the wire while leaving room for movement
Variable Force Orthodontics Delta Force Bracket Features The Delta Force Bracket ndash A Change for the Better The Delta Force Bracket System incorporates an advanced design that allows you to control the friction between the archwire bracket and ligatures
The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results
Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces
Delta Force Ligation Options
Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment
Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control
Minimum Force Maximum Force
Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire
Minimum Force Maximum Force
Medium Force
Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation
Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Variable Force Orthodontics Delta Force Bracket Features The Delta Force Bracket ndash A Change for the Better The Delta Force Bracket System incorporates an advanced design that allows you to control the friction between the archwire bracket and ligatures
The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results
Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces
Delta Force Ligation Options
Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment
Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control
Minimum Force Maximum Force
Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire
Minimum Force Maximum Force
Medium Force
Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation
Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results
Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces
Delta Force Ligation Options
Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment
Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control
Minimum Force Maximum Force
Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire
Minimum Force Maximum Force
Medium Force
Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation
Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces
Delta Force Ligation Options
Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment
Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control
Minimum Force Maximum Force
Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire
Minimum Force Maximum Force
Medium Force
Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation
Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Delta Force Ligation Options
Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment
Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control
Minimum Force Maximum Force
Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire
Minimum Force Maximum Force
Medium Force
Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation
Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control
Minimum Force Maximum Force
Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire
Minimum Force Maximum Force
Medium Force
Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation
Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire
Minimum Force Maximum Force
Medium Force
Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation
Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation
Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT
METAL LIGATURE TIES
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
The vast majority of fixed orthodontic appliances have stored
tooth-moving forces in archwires which are deformed within their
elastic limit For this force to be transmitted to a tooth wires need a
form of connection to the bracket
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly
established orthodontic terms
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Elastomeric modules are adversely affected by oral
environment demonstrates stress relaxation with time and exhibit great individual variation in properties
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
The normal force exerted by the ligature
has been estimated to be between 50 to
300 g
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Bazakidou showed that there was no significant
differences between frictional resistance offered
by the conventional tied stainless steel ligature
and elastomeric module
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Frictional forces can be reduced by
stretching the elastomeric modules prior
to placement on the brackets or by tying
stainless steel ligatures loosely around
the brackets
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
On the other hand stainless steel ligatures
can be too tight or too loose depending
upon the technique and needs of the clinician
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Stainless Steel Ligatures
When stainless steel became available this was universally
adopted as the method of ligation Stainless steel ligatures
have several beneficial inherent qualities They are cheap
robust and essentially free from deformation and
degradation and to an extent they can be applied tightly or
loosely to the arch wire
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Stainless Steel Ligatures
They also permit ligation of the archwire at a distance from
the bracket This distant ligation is particularly useful if the
appliance tends to employ high forces from the archwires
because this high force prevents sensible full archwire
engagement with significantly irregular teeth
Kobayashi Ties
Add an auxiliary hook to any bracket
Available in 010 012 or 014
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Composite ligaturebull Fabricated from the acrylic monomer n-
butyl methacrylate and drawn poly
ethylene fibers
bull Due to stress relaxation properties
within an hour it loss 98 of ligation
forces( not used in sliding mechanism)
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Specially formulated almond color coating
will not peel For use with ceramic or
plastic brackets
Teflon coated Ligature bull No discoloration
bull The coating wears off after 2-3 weeks and the metal is
exposed
bull Produces less friction when compared with elastomeric
ligatures amp stainless steel ligatures
bull It generates lighter forces of engagement of the arch
wire into bracket slot
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)
Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Despite these good qualities and their widespread use over
many decades wire ligatures have substantial drawbacks
and the most immediately apparent of these are the length
of time required to place and remove the ligatures
Preformed Ligature Ties
bullPreformed in dead soft temper
bullAvailable in long or prendashcut
Stainless Steel Ligatures
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
One typical study found that an additional 11 minutes was
required to remove and replace two archwires if wire
ligatures were used rather than elastomeric ligatures
Bulk Ligature Spools
bull1 pound spools
bullBright finish with soft temper for
ease of use
Stainless Steel Ligatures
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Stainless Steel Ligatures
Additional potential hazards include those
arising from puncture wounds from the ligature
ends and trauma to the patientsrsquo mucosa if the
ligature end becomes displaced
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
The use of stainless steel ligature ties has been shown to
increase friction through a dual mechanism There is a
higher engagement force between the archwire and bracket
and additional friction is generated by the contact of the
ligature surface with the archwire however elastomeric
ligatures can induce the same effects
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
A practical conclusion from these studies
was that self- ligating brackets showed
less frictional forces while the figure-of-
eight ligature configuration increased
friction significantly
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Conventional brackets received metallic ligatures used to tie
the arch to the slots (A) always carefully bending them
perpendicular to the leveling arch (B) in order to reduce
plaque retention
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Comparative Thickness of MPA
A Multi-Purpose Attachment -MPA can be used in different conditions The
thickness of an MPA is very less as compared to the conventional brackets
and tubes It has a body that is very thin - 04 mm and a lumen through
which a ligature wire or an 0016 arch wire can pass Curved MPAs are for
the canines premolars and molars and the flat ones are for the incisors
Multi-Purpose Attachment
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
EYELET
DIRECT BOND
Easily bonded to any tooth Specially designed base provides
a firmer bonding strength 10 per package
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Stainless Steel Ligatures
Single Tie
One end of a small piece of ligature wire is passed through the
lumen of the attachment It is then passed under the arch wire on
the other side twisted around the other end cut and tucked in
This tie can be given for aligning and leveling a tooth
Methods of Ligation
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Stainless Steel LigaturesDouble Tie
One end of a small piece of ligature wire is passed through the lumen of the
attachment It is taken labial to the arch wire on the other side and reinserted
into the lumen from the same side After pulling out completely to the side
from where it was inserted earlier it is twisted around the other end of the
ligature wire cut and tucked in This tie can be given to correct rotation and to
upright a tooth
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can
be bonded initially Once crowding is relieved a bracket can be bonded after
debonding the MPA
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite
plate to disocclude the teeth in cross bite or else the brackets may debond or
the patient would be uncomfortable In such a case an MPA can be bonded as
incisal as possible on to a tooth in cross bite and the main arch wire can be tied
to the attachment to get the tooth into alignment
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
If the deep bite is more than 3 to 4 mm then a posterior bite
plate may be necessary until the tooth in cross bite crosses
over the opposing tooth Many a times it is difficult to bond
brackets on to the lower incisors in deep bite cases Deep bite
may be of a single tooth or of multiple teeth
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Occlusal interference with even one tooth would be
uncomfortable and painful to the patient or it would
cause bond failure resulting in extended treatment
duration Teeth in scissors bite can also be corrected
with this attachment
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Small clinical crownsAn MPA can be bonded onto the occlusal surface of a
tooth with a small clinical crown and brought into
alignment
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
A hook can be made by twisting the strands of a piece of
ligature wire after passing it through the lumen of the
attachment Even if the tooth gets covered by gingiva after
some time the hook remains out and can be used for tying
ligatures or elastomerics to the main arch wire to get the
tooth in occlusion and alignment
Impacted Teeth
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
As the tooth erupts the hook can be shortened
by cutting and bending it
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Uprighting Second Molars
An impacted lower second or third molar can be
corrected by bonding an MPA and giving a spring which
distalizes and uprights the molar
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
It is acknowledged that metallic
ligatures produce around 30 to
50 of friction caused by
elastomeric ligatures
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Little Effort Big Results by Andrew Hayes DDS
The everyday task of handling extraction spaces is an art in its
own right with an endless list of variables that require
clarification
Do you extract before or after bracketing
bullCanine retraction or en-masse retraction
bullMaximum or minimum anchorage
bullReciprocal space closure
bullLeveling and aligning before any space closure for sliding
bullActive or passive brackets in the buccal segments
bullSkeletal anchorage
bullPeriodontally or osteogenically accelerated orthodontics
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
The terms laceback and tieback have been commonplace in
the field of orthodontics for some time and are often
substituted for each other when theyre actually different
entities
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Laceback was popularized by McLaughlin and Bennett in
the late 1980s 1 They described lacebacks as using 010
stainless steel ligature wires extending from the most
distally banded molar to the canine bracket
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Lacebacks are generally placed on the brackets before
the insertion and ligation of the archwire The purpose
is to restrict canine crowns from tipping forward
during leveling and aligningmdasha tipping caused by the
addition of angulation in todays prescription brackets
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Tieback refers to the use of stainless steel ligatures threaded
through an elastic module that goes directly from the terminal
molar to the canine bracket Unlike the laceback this type of
ligation is done after the placement and ligation of the archwire and
is commonly used for active space closure
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Clinical trials have shown both active tieback and active laceback
methods to be reliable in anterior retraction3 4The active tieback
method using an elastomeric module has shown to have a clinically
significant decrease in space-closure time compared with the
laceback method with no elastic module Elastic modules when
prestretched to twice their original size have been shown to deliver
50-150g of force initially2
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Canine retraction with active tiebacks is often rapid and has
minimal unwanted side effects even when using with light initial
nickel titanium archwires It is important to note that there is no
mesial-outdistal-in rotation evident on the canines that typically
seen with elastic chain or coil-spring retraction
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
It has been shown that the canines rotate 268 degrees
on average with laceback tie compared with 775
degrees with coil springs4 One study suggests that
using the tieback method of space closure has more
appropriate initial force than elastomeric chain5
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks
that when theyre placed its not uncommon to see entire
extraction spaces close up on their own and severe crowding to
align at an astounding rate
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Clinical caseA 13-year-old male presented for treatment with slight
overbite and overjet and maxillary canines actively erupting
toward the buccal The posterior occlusion was Class I molar
left and full step Class III molar on the right side resulting
in a significant mandibular midline discrepancy
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
The patient had a straight facial profile good lip
competency and mild chin deviation to the left In spite of
the asymmetric Class III dentition the resulting chin
deviation was mild enough to be considered within normal
limits
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Mandibular mid line is deviated to the left
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Cephalometric analysis revealed a strong Class III
component with severe dental compensation At 73 degrees
the lower incisors were retroclined approximately 20 degrees
from the norm Although ANB was only slightly negative the
Wits appraisal came out to -93mm Because of the severity of
the Class III skeletal component and the patient being in
active growth the likelihood of future surgery was discussed
before any treatment
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
bullTreatment planBegin with maxillary arch only
bullBond to create space for maxillary canine teeth
bullImprove overbite and overjet
bullWhen maxillary teeth aligned bond sectional wire to
Class III side
bullPlace active tieback from 30-27
bullExtract tooth 28
bullBond lower arch only when 27 is in Class I position
bullRe-evaluate for lower arch miniscrews in external oblique
ridge if necessary for retraction
bullClass III elastics prn
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Treatment sequencingThe patients maxillary arch was bonded to include all teeth except
unerupted canines After three months adequate space was created
to bond the erupted canines After six months of maxillary-only
appliances no significant mandibular growth had taken place
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Because of this bonding a lower sectional appliance
from molar to canine on the Class III side was done A
0014 NiTi wire was used and an active tieback placed
before dental extraction
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
This complex asymmetric Class III case has treated out quite well
and efficiently The use of the active tieback to close the extraction
space provided all the anchorage necessary in this maximum
anchorage situation Why arent all complex orthodontic cases
requiring extraction being treated this way and completed in 15-18
months After all its extremely simple to do the molars are great
anchorage and best of all the RAP is free turbocharging for space
closure
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
The majority of articles discussing retraction with tiebacks or lacebacks
typically conclude that the canine retraction is adequate but there is
significant posterior anchorage loss associated A recent meta-analysis
concluded There is no evidence to support the use of lacebacks for the
control of the sagittal position of the incisors during initial orthodontic
alignment Another recent article concluded Active laceback produced
anchorage loss of maxillary first molars3
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
It has been shown that teeth move faster in
proximity to a recent extraction compared with a
healed extraction site
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
If one follows the MBT philosophy step by step McLaughlin proposes a waiting
period for space closure with passive tiebacks or lacebacks until true passive
insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving
sliding mechanics Without a protocol for having the tieback in place before or
immediately after extraction one may be missing out on a great deal of Mother
Natures own tooth-moving accelerator the RAP In fact the increase in cellular
activity is so great that Frost documented that RAP can expedite hard- and soft-
tissue healing stages between two and 10 times that of normal physiological activity
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
A 2013 study stated that extractions can be a good source for inflammatory
markers (These markers play an important role in osteoclast recruitment)
Because of this the group proposed that when possible extractions should be
delayed until the time of major tooth movement16
What if our patients are getting the extractions before initiating orthodontics
or if theyre in orthodontic treatment and have the extractions performed but
dont see us for six weeks What if were waiting for our large-diameter wire to
become completely passive Orthodontic literature has shown that extraction
undoubtedly leads to decreased bone density in the extraction17 18 Could we be
missing out on the wonderful advantages that biology has to offer
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Figure 8 ligation to maintain
diastema closure
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces
bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used
bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Serpentine wires- 1 week before appliance removal UampL arch
wires are removed ligated together in a serpentine fashion from PM
to PM with std ligature wire--- occlusion to settle without any
interdental spacingndash (in minimal discrepancies of tooth position)
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a
0016-inch nickel-titanium wire Because extraction patients often exhibit more initial
crowding in the maxillary arch than do nonextraction patients this flexible wire is often
used for one to two additional appointments This archwire will correct the crowding
reduce the rotations and help level the teeth Because the point of least resistance is toward
the extraction site there is little flaring of the incisors as they align Most of the tooth
movement is into the extraction sites To make this even more effective the special low-
friction ligation can be placed on those teeth that need the greatest amount of movement
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Modified laceback for canine retraction
The ligature wire is placed without the placement
of the arch wire
The arch wire is then placed with the open coil spring
and the canine bracket is ligated with metal ligatures
The ends of the ligatures are brought
forward and tied with the compression of
the open coil spring
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Retraction of upper incisors
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Class I malocclusion with severe double
protrusion treated with first premolars
extraction
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
En-masse retraction of anterior teeth
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
Effect of force applied to the orthodontic archwire
during sliding mechanics associated with mini-
implants
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
In cases with reduced or normal overbite the orthodontic
treatment should be initiated with individual retraction of the
canines and application of horizontal forces without any
vertical force components which are not helpful in these
patients
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125
References
1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric
ligatures Indian J Dent Res 20112295-9
5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125