Development of contemporary fixed appliance /certified fixed orthodontic courses by Indian dental academy

DEVELOPMENT OF CONTEMPORARY FIXED APPLIANCE

INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

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CONTENTS

□INTRODUCTION □FAUCHARD□ MAGILL□EDWARD H.ANGLE□ANGLE’S FIRST APPLIANCE MECHANICALLY

FLAWED□CAVIN S.CASE□ANGLE’S GREAT DILEMMA□QUEST


INTRODUCTION

□Even the Ancient Egyptians (~3000 BC) were concerned with straightening teeth, as mummies have been found to have crude metal bands wrapped around individual teeth with catgut to close spaces

□But regulation of teeth, as orthodontic alignment was formerly referred to, did not gain significant attention until Pierre Fauchard 1678-1793, French, who is considered the “Father of Modern Dentistry” and “Orthodontia,” developed the bandeauor bandolet in 1723


FAUCHARD

□This was the first expansion appliance,consisting of a heavy maxillary labial arch of precious metal to which teeth were ligated, and was the basis for Angle’s E(expansion)-Arch

□Western Europe continued to be the center of orthodontic developments during the 18th and early 19th centuries


FAUCHARD ( 1728 )

□Fauchard from France introduced a bow , affixed to external surfaces of teeth

□This was the forerunner of modern arch wire


FAUCHARD’S APPLIANCE


MAGILL

□Used a plain band cemented to tooth by oxychloride of zinc cement


EDWARD H.ANGLE ( 1855 – 1930 )

□ Edward Angle referred as “FATHER OF MODERN ORTHODONTICS” has contributed to the development of new orthodontic appliances

□ With few exceptions, fixed appliance used in contemporary orthodontics are based on Angle’s design from the early 20th century

□ Developed four major appliance systems

Edward H.Angle


ANGLE'S FIRST APPLIANCE ALSO MECHANICALLY

FLAWED□Ironically, both Angle's first and last

published appliances had similar flaws- neither facilitated the retraction of teeth to close spaces or correct anteroposterior discrepancies

□The first appliance, presented in 1887 (Irregularities of the teeth, presented before the Ninth International Medical Congress, Washington DC,USA), was intended to retract a canine distally into a first premolar extraction site



FLAWED□However, careful analysis of the mechanics involved, followed by analysis of the application of force and subsequent tooth responses, reveals that the second molar, which was intended to offer resistance to the traction force, was free to rotate distobuccally

□ The tube on the canine, being horizontal, set up anchorage in the very tooth to be moved. Angle would later refer to such teeth as being stationary anchorage



FLAWED□The following year, Angle corrected

the mechanical errors at both ends of his traction force in an article with a title giving an indication of this 32-year-old's growing sense of confidence: "New System of Regulation and Retention."


Angle's first appliance intended to retract a canine distally. Faulty design set up

anchorage in the canine and permitted rotation of the second molar.

The Edgewise Slot: Angle's Orthodontic AlbatrossPeter C. Kesling, DDS, ScD, Private Practice of Orthodontics, Westville, Indiana, USA. www.indiandentalacademy.com


FLAWED□In his revised appliance, the second

premolar and the first permanent molar were transformed into a stationary anchorage unit by soldering a horizontal tube onto bands around both teeth

□The canine crown was permitted to tip distally by placing a tube horizontally on its mesial surface

□Angle would later refer to such tipping movement as "simple anchorage."


Corrected design permitted distaltipping of the canine and provided

anchorage from both the second premolar and first molar



FLAWED□The importance of this new arrangement--

tipping of the tooth to be moved and bodily movement of the resistance teeth--was stressed by Angle in his sixth edition, published 10 years later, by an illustration that appeared 4 times along with the following words: "Be it remembered that the tube attached to the cuspid band must always stand at right angles to the long axis of the tooth, that a free hinge-like movement of the tooth in retraction may be gained...."


Buccal view of Angle's perfected traction screw

Note: Dotted lines indicate Angle's perception

that heavy forces caused the canine to tip about a

fulcrum near the gingival crest and the molar to move bodily


CALVIN S.CASE ( 1847 – 1923 )

□ Calvin S. Case, had invented and promoted appliances that could tip crowns, "force the roots," or move teeth bodily.

□ Upper and lower arch bars with threaded ends were loosely connected to the ends of vertical bars soldered to bands on the anterior teeth

Calvin S.Case


CALVIN S.CASE ( 1847 – 1923 )

□Contributed greatly to the orthodontic literature but was the first to try bodily tooth movement with the contouring apparatus, to use light wires (0.016” and 0.018”gold)


(a)Contouring appliance to "bodily" protrude root tip. Power bow (P) is activated by tightening the nut

mesial to its sheath. Fulcrum bar (F) provides traction by tightening the nut at its end.


(b)Apparatus for retracting the root and moving the incisal edge forward. Both bars are activated by

tightening the nuts against their respective sheaths. Designs of both appliances permit

movement by the power bars without adjusting the nuts on the fulcrum bars. By placing the nuts of both the upperand lower arch bars on the same ends of the buccal sheaths, teeth can be moved

bodily--labially or lingually


CALVIN S.CASE

□Case had an extremely capable, although cumbersome and potentially powerful, new appliance to both tip and upright teeth

□ He later termed this his "Contouring Apparatus," because he felt that when maxillary roots were moved forward and laterally more than their crowns, the middle features of the face achieved a fuller contour


ANGLE'S GREAT DILEMMA

□Sometime after the publication of his sixth edition in 1900, which is replete with extraction devices, Angle found himself in a dilemma

□His new text included appliances designed to tip teeth, yet by then he realized nature could not be relied upon to subsequently upright them

□He had no efficient mechanism to direct the roots


ANGLE'S GREAT DILEMMA

□Angle appreciated that it was not advantageous to attempt to move a tooth while keeping it upright--a tooth that cannot tip is, in effect, an anchor tooth

□Angle came up with the only instant solution to the problem--stop extracting teeth

□Angle presented his nonextraction stance in a paper read before the American Society of Orthodontists in October 1902

.


QUEST FOR THE ULTIMATENON EXTRACTION

APPLIANCE□For the next 25 years, Angle continued his search for a better "mousetrap."

□This led him through a series of nonextraction appliances, including the E (expansion) Arch.

□These were followed by the pin-and-tube appliance of 1910 and the ribbonarch appliance of 1915.

□Both the 1910 and 1915 Angle appliances were designed to expand the crowns and then move the roots labially. The pin-and-tube was extremely difficult to manipulate



APPLIANCE□The ribbon-arch bracket contained

the first practical archwire slot, which facilitated archwire changes and could provide torque with a ribbon archwire

□However, since the slots faced vertically, the teeth were free to tip mesially or distally



APPLIANCE□ Finally, in 1925, as a means to provide positive

mesiodistal angular control, Angle invented what would become known as the edgewise appliance. The "open face“ or tie bracket was a clever modification of the ribbon-arch bracket

□ He cut an archwire slot in its face and added an extension (wing) to its gingival end

□ The labial wall of the original vertical archwire slot formed the incisal wing

□ The original ribbon archwire was rotated 90 degrees and inserted "edgewise" into the horizontally facing slot

□ P. R. Begg, a student of Angle's in 1925, cut the first prototypes on a lathe



APPLIANCE□ This resulted in the first positive, yet simple, 3-

dimensional tooth control between an archwire and slot

□ An archwire, round in cross section, could be used for initial expansion to permit buccal or labial tipping of the crowns

□ Subsequently, a rectangular archwire could be used to torque roots labially or buccally with hopes, in some cases, of stimulating bone growth

□ The appliance, like the ribbon-arch, was small and delicate, yet relatively easy to manipulate.



APPLIANCE□ However, Angle's "latest and best" provided so

much control it was difficult to make the anteroposterior interarch corrections necessary to treat Class II or III discrepancies

□ The archwire slot did not permit mesial or distal crown tipping.

□ Angle had forgotten the lesson he had learned 38 years before, "...[A] free hinge like movement of the tooth in retraction [must] be gained…." His last modification to the appliance, second-order bends in the archwire, could not provide the free tipping required


ANGLE’S PROGRESSION FROM E – ARCH TO EDGEWISE APPLIANCE


E – ARCH ( 1900 )

□Angle’s first appliance□Basic design : Had rigid framework to

which teeth has been tied so that they could be expanded to arch form dictated by the appliance

□Bands were placed only on molar teeth and a heavy labial archwire extended around the arch

□End of the wire was threaded and a small nut placed on the threaded portion of the arch allowed archwire to be advanced so that arch perimeter increased


E - ARCH

□The E-arch was comprised of ligatures from a heavy (0.036” – 0.060” gold) labial arch that brought misaligned teeth to the line of occlusion


E – ARCH ( 1900 )

□ Individual teeth were simply ligated to this expansion arch

□ First to utilize stationary anchorage or bosily control of first permanent molar teeth which were fitted with clamp bends

□ Expansion arch was threaded to form a traction screw arrangment attached to the buccal of anchor bands


E - ARCH

DISADVANTAGES:□It can deliver only

heavy interrupted force

□Capable only of tipping teeth to a new position

□Was not able to precisely position any individual teeth Angle’s E - Arch


PIN AND TUBE APPLIANCE(1910)

□First appliance that employed a bracket and used bands on most of the teeth

□Angle placed bands on other teeth apart from molars and used a vertical tube on each tooth into which a soldered pin from a smaller archwire was placed

□Tooth movement was accomplished by repositioning the individual pins at each appointment


PIN AND TUBE APPLIANCE(1910)

□These pins were repositioned at each appointment through the process of resoldering to effect gradual straightening of the arch to ideal


PIN AND TUBE APPLIANCE( 1910 )

DISADVANTAGES:□An incredible degree of craftsmanship was

involved in constructing and adjusting this pin and tube appliance

□Relatively heavy base arch meant that spring qualities were poor

□Many small adjustments were needed□Only Angle himself and one of his students

ever mastered the appliance


PIN AND TUBE APPLIANCE


RIBBON ARCH APPLIANCE ( 1915 )

□Angle attempted to achieve three-axis control of tooth movement when he introduced the Ribbon Arch in 1916 , a rectangular 0.036” x 0.022” gold arch wire held firmly with pins into vertically positioned rectangular slots


RIBBON ARCH APPLIANCE


RIBBON ARCH APPLIANCE


RIBBON ARCH APPLIANCE(1915)

□Angle modified the tube on each tooth to provide a vertically positioned rectangular slot behind the tube

□A ribbon arch of 10 X 20 gold wire was placed into the slot and held with pins

□Was an immediate success primarily because the archwire was small enough to have good spring qualities and was quite efficient in aligning malposed teeth




RIBBON ARCH APPLIANCE(1915)

□The ends of the ribbon arch were threaded, and the malocclusion was “ironed out” through expansion

□The ribbon arch wire was smaller in the horizontal direction, therefore possessing better spring qualities, and this was the first appliance with full three-axis control of tooth movement (especially the incisors and canines)

□However, the ribbon arch still had relatively poor control of root positions, especially in the premolar regions


DISADVANTAGES

□Provided relatively poor control of root position

□Resiliency of the appliance did not allow generation of moments necessary to torque roots to a new position


EDGEWISE APPLIANCE (1928 )

□Angle re oriented the slot from vertical to horizontal and inserted a rectangular wire rotated 90 degrees to the orientation it had with the ribbon arch

□Dimensions of the slot were altered to 22 x 28 mils and a 22 x 28 precious metal wire was used

□These dimensions arrived after excessive experimentation did not allow excellent control of crown and root position in all three planes of space


EDGEWISE APPLIANCE (1928 )

□ Rectangular brackets with gingival and occlusal wings were soldered to bands at the center of the labial surface, and ¾ rings (“doughnuts”) were soldered off –center to correct rotations

□ This appliance soon became the most popular appliance in the U.S., as it was the first to move teeth in all three planes of space simultaneously, and it controlled premolars because the wider dimension of the arch wire was in the horizontal dimension

□ Modern appliances are based on Angle’s edgewise concept, only with several modifications and variations


EDGE WISE BRACKETS


EDGEWISE BRACKETS BONDED ON TEETH


OTHER EARLY FIXED APPLIANCE SYSTEMS


LINGUAL ARCH

□ John V. Mershon introduced his lingual arch in 1908 , made of 0.036” or 0.040” gold arch with auxiliary spring that were used during growth with intermittent rest periods, and was considered the first “invisible appliance. LINGUAL ARCH


LABIOLINGUAL APPLIANCE

□Between 1920 and 1940, Mershon developed the Labio-Lingual appliance made of labial and lingual 0.040” gold wires with banded incisors and premolars

□The attachments, limited only by the practitioner’s creativity, were only able to tip teeth, yet teeth had functional freedom

□Bands were placed on first molars and a combination of heavy lingual and labial archwires to which finger springs were soldered to move individual teeth


LABIO LINGUAL APPLIANCE


OPEN TUBE APPLIANCE

□ In 1922, James McCoy developed the open-tube appliance, in which an 0.030” or 0.036” gold round arch wire was inserted into a horizontal bracket (a tube with 40% cutout), so there was no torque control and this “self-ligation” was brutal

OPEN TUBE APPLIANCE


UNIVERSAL APPLIANCE

□ Spencer R. Atkinson (1886-1970)invented the Universal appliance in 1929,which was introduced in 1937 as a combination of the ribbon-arch and edgewise appliances, and followed Oppenheim’s theory of using light forces

□ All permanent teeth were banded and the operator could use a round wire and/or a ribbon arch wire; where the round gingival wire could achieve mesio-distal and extrusion - intrusion movements, and the ribbon occlusal wire would accomplish rotations and buccolingual movements

□ The West’s first orthodontic supply house, Unitek Corporation, made the first brackets for the Universal Technique


ATKINSON’S UNIVERSASL APPLIANCE


TWIN WIRE APPLIANCE

□ E. Johnson (1888-1969) introduced the Twin-wire appliance in 1932 , in which incisors and molars were banded, twin 0.010” steel arch wires were used that were more physiologic than one heavy arch wire

Joseph E. Johnson


TWIN WIRE APPLIANCE

□Bands were placed on incisors and molars

□Twin 10 mil steel archwires for alignment of incisor teeth

□Delicate wires were protected by long tubes that extended forward from the molars to the vicinity of canines


TWIN WIRE APPLIANCE

□The twin-wire appliance successfully aligned incisor teeth, effectively leveled and derotated, and was more comfortable because of lighter forces


DISADVANTAGES

□None of these appliance were capable of more than tipping movements except with special and unusual modifications

□Lacked anterior torque control, and did not control canines or premolars, and was not suitable for extraction cases

□Disappeared from contemporary use


Dr.R.D.Robinson ( 1915 )

□Developed an appliance that utilized light forces with constant control of roots of teeth

□Attachments and wire he used made employment of differential forces impossible


Dr.E.M.GRIFFIN ( 1930 )

□Developed a resilient arch assembly□Center sections of brackets were

soldered to arch wire, preventing free tipping and sliding of teeth on the wire

□Lingual arch wires were also employed


CHARLES TWEED

□C. H. Tweed perfected a technique in the 1940s using tip-back bends to facilitate retraction and close spaces in spite of the limitations imposed by Angle's slot

□In 1941, he wrote, "…[C]uspid tip back bends are necessary. Their purpose is to break down the…toe hold…present in the cuspid regions”

□His results were excellent, but the price, as measured in long appointments, wire bending, and patient cooperation, was extremely high


CHARLES TWEED

□Adapted the edge wise appliance for extraction treatment

□Tweed moved the teeth bodily and used the subdivision approach for anchorage control, first sliding the canines distally along the archwire , then retracting the incisors

CHARLES H.TWEED


P.RAYMOND BEGG

□In 1933, P.Raymond Begg (1889 - 1983 ) developed his own bracket because he found it difficult to close extraction spaces and correct deep overbites using the edgewise appliance


BEGG APPLIANCE

□ RAYMOND BEGG had been taught use of ribbon arch at ANGLE SCHOOL

□ Working independently, he concluded that extraction of teeth was often necessary and set out to adapt the ribbon arch appliance so that it could be used for better control of root position Raymond S.Begg


BEGG APPLIANCE

□By the late 1920s, Begg had reverted to the use of ribbon-arch brackets

□They permitted all teeth to tip to facilitate anteroposterior interarch corrections and to close extraction spaces. However, at that time Begg also lacked an efficient means of mesiodistal axial control

□This forced him to select cases for publication, as Angle did with his traction screws, that required little or no root uprighting


BEGG APPLIANCE

□ The Begg appliance consists of a narrow ribbon-arch bracket turned upside down, single stainless steel round archwires (0.016” or less), greater interbracket distance, and interbracket loops to control the degree and duration of force

□ In the 1960s, Begg invented both the uprighting spring and torquing auxiliaries

□ These enabled him and many others to utilize differential tooth movement, crown tipping followed by root uprighting, to consistently treat the most difficult of malocclusions


(a) Original mesiodistal uprighting spring introduced by Begg in 1961 for use with modified ribbon-arch

brackets (b) Combination spring and lock pin (1974) eliminates need for ligation


BEGG APPLIANCE

□ Begg’s adaptation took three forms1. He replaced the precious metal ribbon

arch with high strength 16 mil stainless steel wire ( 1930 )

2. He retained the original ribbon arch bracket but turned it upside down so that the bracket slot pointed gingivally rather than occlusally

3. He added auxiliary springs appliance for control of root position


BEGG APPLIANCE

□Treatment with this appliance was challenging during the finishing stage due to poor root torque control

□To address the difficulties with final root positions, some practitioners began using the combination twin edgewise and light-wire technique : first stage using 0.016” stainless steel single strand for tipping, second stage of multistrand (6 x 0.008” or 4 x 0.009”) wires for controlled general alignment, and a third stage of engaging a final edgewise wire


BEGG APPLIANCE

□Friction was minimized because the area of contact between the narrow ribbon arch bracket and archwire was very small and force of the wire against the bracket was small

□Begg’s strategy for anchorage control was TIPPING / UPRIGHTING

□Begg appliance is still in use though it has declined in its popularity and often appears now in a hybrid form, with brackets that allow the use of rectangular wires in finishing


CONTEMPORARY EDGEWISE

□Contemporary edgewise appliance has evolved far beyond the original design while retaining the basic principle of a rectangular wire in a rectangular slot and now is more efficient than the begg appliance – which is the reason for its almost universal use now


TIP EDGE BRACKETS

□ Peter C. Kesling developed the Tip-Edge bracket (trademarked by TP Orthodontics) in 1986, by removing opposite corners of the edgewise bracket, to allow mesial and distal crown tipping during initial stages and engagement of rectangular wires for torque control during finishing stages

□ The effective Tip-Edge slot increases with tipping, while the conventional edgewise slot size decreases

□ The bracket also features lateral wings for rotational control, and tie wing notches and a vertical slot for use with auxiliaries


Modification of Angle's edgewise archwire slot into a Tip-Edge slot

(a) Original slot with parallel opposed upper and lower surfaces

(b) Removal of diagonally opposed corners to permit free crown-tipping in one

direction only(c) Addition of lateral wings for increased

rotational control plus tie wing notches and vertical slot for auxiliaries


LAWRENCE F.ANDREWS

□ The most revolutionary advancement in orthodontics within the past 50 years has been Lawrence F. Andrews’ development of the Straight-Wire Appliance (SWA) in 1970

□ This pre adjusted appliance soon became the standard of the specialty

□ The SWA was based on measurements of 120 non-orthodontic normal cases, from which Andrews described the “Six Keys to Normal Occlusion.”

□ He designed individual brackets for each tooth type to work without wire bending, because he found that when in optimal occlusion, there exists extensive similarities in morphology and position of normal tooth types


STRAIGHT WIRE APPLIANCE

□ From his extensive measurements, Andrews determined the average tip and torque angles and in/out dimensions of the labial surface of each tooth relative to a flat labial arch wire plane, coined the “Andrews’ Plane”

□ When each pre adjusted bracket was precisely positioned at the midpoint of each tooth’s facial axis, the brackets formed the Straight-Wire Appliance

□ He also developed a series of extraction brackets which include anti-tip and anti rotation components not found in the Standard SWA prescription


OTHERS

□Use of Andrews’ prescription throughout the specialty has shown that ideal tooth positions are sometimes not achieved with straight wires alone, and therefore numerous additional prescriptions have been developed by others, including Roth, Ricketts, Alexander (1978 ), Hilgers, Burstone, Root/Tweed, Cetlin, Bench, Creekmore, Hasund, Orthos,and McLaughlin/Bennett (1997 – 2001 ) / Trevisi


EVOLUTION OF BRACKETS


CONCLUSION

□Orthodontic appliance technology continues to develop

□Self-ligating brackets, computerized bracket placement, esthetic brackets and implant anchorage are currently making history

□However, without a good diagnosis and treatment plan, and careful management of the treatment process, improved appliances cannot bring us closer to ideal treatment goals


REFERENCES

□Wahl, N. “Orthodontics in 3 millennia.” (Chapter 1: Antiquity to the mid-19th century.) Am J Orthod Dentofacial Orthop;127:255-259; 2005.

□ArchWired. “A Brief History of Braces.” p. Review of Orthodontic History; 2005

□Wahl, N. “Orthodontics in 3 millennia.” (Chapter 2: Entering the modern era.) Am J Orthod Dentofacial Orthop;127:510- 515; 2005


REFERENCES

□Kesling, P. “The Edgewise Slot: Angle’s Orthodontic Albatross.” World Journal of Orthodontics;1:142-151; 2000.

□Wahl, N. “Orthodontics in 3 millennia.” (Chapter 5:The American Board of Orthodontics, Albert Ketcham, and early 20th-century appliances) Am J Orthod Dentofacial Orthop;128:535-540; 2005


REFERENCES

□Proffit, W.R., White, R.P., Sarver, D.M. Contemporary treatment of dentofacial deformity. St. Louis, Mo.: Mosby;p. ix, 751 p.; 2003.

□Dewel, B.F. “The ribbon arch. Its infl uence in the development of orthodontic appliances.” Angle Orthod; 51:263-268; 1981.

□Strang, R.H. “Highlights of sixty-four years in orthodontics.” Angle Orthod ; 44:101-112; 1974.


REFERENCES

□ Wahl, N. “Orthodontics in 3 millennia.” (Chapter 6: More early 20th-century appliances and the extraction controversy) Am J Orthod Dentofacial Orthop; 128:795-800; 2005

□ Begg, P.R, Kesling, P.C. “The differential force method of orthodontic treatment.” Am J Orthod;71:1-39;1977.

□ Kesling, P.C. “Dynamics of the Tip-edge bracket.” Am J Orthod Dentofacial Orthop;;96:16-25; 1989.

□ Graber, T.M, Vanarsdall RL. Orthodontics : current principles and techniques. St. Louis: Mosby; 2000.


REFERENCES

□Andrews, L.F. Straight Wire: The Concept and Appliance.San Diego, CA: L.A. Wells Co.; 2003.


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Development of contemporary fixed appliance /certified fixed orthodontic courses by Indian dental academy