ADVANCED PASSIVE SELF-LIGATION CASE SET-UP 167

EXCELLENCE IN ORTHODONTICS 2012

Chapter

9
Advanced case set-up and the first
four visits
David Birnie
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Introduction
The way a case is set up is both an extension of the diagnostic process and the start of the finishing process. It is
therefore crucially important to get this part of treatment as right as possible in order to ensure a high quality
result is obtained in the minimum amount of time. Much has changed in this arena in the last 18 to 24 months
and this chapter reflects current thought.

Simultaneous or sequential mechanics?

Traditionally, orthodontic treatment has been done in a sequential fashion similar to the following stages:

• alignment and derotation

• levelling and overbite reduction
• torque control and overjet reduction
• extraction space closure
• finishing

Sequential mechanics is predicated on most significant group tooth movement being done in ‘working’ archwires
– normally stainless steel 0.019” x 0.025”. The problems of tooth control with conventionally ligated appliances
means the early use of space opening, space closing or buccal segment correction mechanics is rare.

Secure ligation means that the above five stages can occur to a large extent simultaneously; the trick is to match
the strength of any space opening mechanics (coil spring), space closing mechanics (power chain) or buccal
segment correction mechanics (inter maxillary elastics) to the rigidity of the archwire so as not to over-power the
archwire.

Initial treatment planning versus case management techniques

All orthodontic treatments need a detailed initial treatment plan; this is derived from clinical observation and
measurement, x-rays and cephalometric analysis, photographs and study models. Plans however do not always
follow intentions – they may become off-plan. Case management techniques are the methods used to bring an
off-plan initial orthodontic treatment plan back on plan. This follows the Plan, Do, Check, Adjust (PDCA) cycle
originally described by Walter Shewart of Bell Laboratories and later popularised by Edward Deming. For
orthodontic treatment, the cycle is like this and repeated until the end of treatment:

Plan initial treatment plan or plan for next visit

Do execute plan (eg: change archwire, start elastics, etc)
Check at next visit, read what changes have taken place
Adjust react by changing mechanics or making other mechanics

This cycle is visit to visit case management; the key to efficient and effective orthodontic treatment is to ensure
that visit to visit case management follows the overall plan without deviation, error or rework. Easy to say but
difficult to do …!

Pitts 6-5-4-6 approach

Tom Pitts has described an approach to the early stages of treatment which helps structure the decisions
necessary to optimise the effect of early treatment mechanics. This approach is based on he sue of passive self-
ligation but it provides a useful structure for any type of appliance system. This includes:

• six decisions that should be made at the start of treatment

• five aesthetic and five occlusal features which should be ‘read’ at each visit
• the fourth visit – photos, panoramic radiograph and repositioning appointment
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• six aspects to focus on during finishing

Six decisions to be made at the start of treatment

These are:

• bracket system and archwire progression

• tooth recontouring
• bracket position
• torque selection
• disarticulation strategy
• early elastics

Bracket system and archwire progression

Clinicians should use the bracket system they are familiar with and which meets their patient’s preferences. Some
bracket systems have less functionality than others; in general, metal brackets have most functionality (eg:
auxiliary vertical and horizontal slots) but aesthetic brackets may be preferred by the patient.

Tooth recontouring
Look carefully to see if any tooth reshaping is necessary. Very pointed upper canines may make it difficult to
produce a final buccal segment relationship that has no intercuspal ‘black space’. Tooth reshaping may need to
be done in two stages; once before the start of treatment and again when alignment has been achieved. Tooth
reshaping may be subtractive or additive.

Subtractive tooth reshaping

This involves reducing tooth structure. Pitts (2009) suggests that most upper canines require reshaping in order to
reduce the height of their cusps and thus ensure a better finish by extruding the broader are of the labial face of
the canine and thus allowing to fit together with the lower arch with less ‘black space’. Adjustment of the lateral
incisors and the upper first premolars may also be necessary at this time. It is sensible to be fairly bold in adjusting
the canine shape but less so with the other teeth; more tooth material can be removed at a later stage if necessary
but not replaced. If reducing an incisal edge, bear in mind the effect of this on the width/height ratio of the incisor
crowns (normally 80%, range 65% to 85%).

Additive tooth reshaping

This can range from repair of a fractured incisor corner to building up a peg-shaped or diminutive tooth. There is
no reason why the temporary build-up cannot be done by the orthodontist using a flowable restorative
composite. For problems of tooth width, space will need to be made to allow the additional width to be added.
Diminutive lateral incisors are best positioned so that of the additional width to be added, one third is added
mesially and two thirds distally; this generally provides the best anterior aesthetics.

It is suggested that gross adjustments of tooth shape are done at the start of treatment or as soon as tooth
position will allow while minor tooth reshaping is done at the end of treatment to finalise and enhance the finish.

Bracket positioning
Careful attention to bracket positioning can significantly affect tooth position. Pitts bracketing is preferred; for
reduced overbites, brackets are placed more gingivally while for deeper overbites, brackets are place on the FA
point. Bracket positioning is becoming individualised to each patient rather than using the same bracket
positioning scheme (eg: FA point) all the time.

Pitts (2009) suggests more gingival positioning of brackets using a line through the mesio-distal contact point line
as a guide.
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• plan using the maxillary canine and

position the incisal tiewings on the mesio-distal
contact point line with the bracket on the
maximum contour of the tooth (usually just
anterior to the FACC). The bracket therefore is
positioned more gingivally and more anteriorly
than is normal
• the lateral incisor bracket is positioned
0.25 mm more gingivally and the central incisor
bracket 0.5 mm more gingivally. Where incisors
are rotated, consider positioning brackets
towards the edge of the tooth most displaced
from the arch to ensure full rotational
correction
• place the maxillary premolar brackets
on the mesio-distal contact point line ensuring
that the brackets are on the maximum height of
the buccal surface contour
Figure 9.1: The mesio-distal contact point line is used as a guide. • the maxillary first molar is placed on
The line of the brackets should progressively diverge towards the anterior the mesio-distal contact point line with buccal
creating a wedge effect
groove on the pad matching the buccal groove
on the tooth; the maxillary second molar is similarly positioned but 1.5 mm occlusal to the mesio-
distal contact point line.

This bracket positioning creates a wire plane which rises as it progresses anteriorly and provides the upper limb of
the wedge effect. A cautionary note is the quality of the enamel is poorer close to the amelo-cemental junction
and particular care should be taken in debonding.

Mandibular brackets and tubes follow a similar logic.

• again, key off the maxillary canine and position the incisal tiewings on the mesio-distal contact
point line with the bracket on the maximum contour of the tooth (usually just anterior to the FACC).
The bracket therefore is positioned more gingivally and more anteriorly than is normal
• for the mandibular incisors, place the bracket parallel to the long axis of the crown with the incisal
tie-wings on the mesio-distal contact line. For anterior open bites place both maxillary and
mandibular incisor brackets approximately 1.5 more gingivally and for deep bites cases, place the
brackets approximately 1.5 mm more incisally. For patients with open bites, it often helps to leave
some curve of Spee.
• for mandibular premolars, place the bracket parallel to the long axis of the tooth and 0.5 mm
gingival to the mesio-distal contact point line

for the maxillary molars, position the buccal groove of the molar tube over the buccal groove of the tooth and
place the occlusal edge of the bracket molar pads 0.5 mm gingivally to the mesio-distal contact point line. Unlike
in the maxilla, both first and second molar tubes have the same vertical positioning in the mandible.

Torque selection
The concept of selective torques is not new however their selection and use has become increasingly refined (see
Thomas 2009). It is helpful to think about:

• what is the inclination of the teeth now?

• what inclination do the teeth need to be at the end of treatment?
• what will happen to the inclination of the teeth during treatment?
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o in deciding this, consider what would happen if you treated the case with round wires only
• will the natural changes that occur during treatment help or hinder your inclination goal?
o remember that in extraction cases, teeth tend to detorque both in the labial and buccal
segments as a consequence of the arch becoming shorter
• what effect will play between the archwire and the bracket slot have? Will it help or prevent
achievement of the final tooth position?
• What effect will your mechanics have (eg: class 2 elastics will tend to retrocline the upper anterior
teeth

This then allows selection of the most appropriate torques to achieve the treatment goal. As an example, non-
extraction class 2 division ii cases often undergo significant inclination change as a result of tooth tipping and
therefore often do not require upper incisor brackets with significant positive torque. In addition, the same tooth
on the contralateral side of the mouth may require a bracket with different inclination characteristics.

While preadjusted brackets have previously been referred to as high and low torque brackets, there is now a move
to rename them positive and negative torque brackets reflecting their ability to increase (positive) or decrease
(negative) inclination.

1 2 3 4 and 5 6 7
Maxilla DQ DQ DQ DQ SL Ti
Positive +22º +13º +11º
Standard +15º +6º +7º -11º -18º -27º
Negative +2º -5º -9º
1 and 2 3 4 5 6 7
Mandible DQ DQ DQ DQ SL Ti
Positive +13º -5º
Standard -3º +7º -12º -17º -28º -10º
Negative -11º 0º
Table 9.1: Selective torques for Damon Q brackets

Methods of applying torque are as follows:

• selective torques
• inverting brackets
• semi-customised selective torques (non standard application of selective torques)
• bending torque in the wire
o manually
o SET (superelastic torqued) archwires
• torquing auxiliary
• fully customised appliance (Insignia, Incognito)

Disarticulation strategy
Disarticulation is a key part of the early stages of treatment and can be applied anteriorly or posteriorly. It can be
used to protect or develop incisor display or smile arcs.

• anterior disarticulation is used in patients with low facial heights, deep overbites and where the
exposure of the upper incisors is not to be reduced. In conjunction with early elastics, it allows
extrusion of the posterior buccal segments. Anterior disarticulation is achieved using anterior bite
turbos (ramps); the preferred material for these is Dentsply Triad Gel which is VLS (visible light cure)
flowable acrylic material available in four shades (colourless, pink, red and blue). OrthoArch Mini
Molds are used to shape the material prior to placement; it is possible to use composite adhesive
but this is not recommended where teeth in the opposing arch contact the ramps as the filler can
cause tooth abrasion. The Triad Gel is much softer and will not damage opposing teeth. The ramps
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can be placed on upper central incisors, upper

lateral incisors or upper canines if the patient has a
significant incisal overjet
• anterior disarticulation can be used in
class 3 cases to aid correction of a class 3 incisor
relationship. In these cases, the turbos are placed
behind the lower incisors.
• posterior disarticulation is used where it is
not desired to increase lower facial height but to
maintain or reduce it. This applies to cases with
anterior open bites and some crossbite cases. Use
Mini Molds again but use the molar pad instead of
the turbo. The pads should be placed on the
mesio-palatal cusps of the upper first and second
molars and the pads equilibrated to ensure and
even contact. In anterior open bite cases, the
patient should be given clenching exercises to try
and achieve posterior intrusion and to strengthen
the masticatory muscles; the effectiveness of these
exercises is uncertain but at worst will simply make
Figure 9.2: The OrthoArch Mini Mold set; the most no difference.
commonly used components are the ramp. the pad and the button

The other Mini Mold that is commonly used is the

lingual button; composite is best used for this as there is no opposing tooth contact and the Triad Gel is too liquid
to reliably fill the more complex mould.

Early elastics
Disarticulation allows the opportunity to use early elastics to effect vertical and antero-posterior changes in the
occlusion free from resistance to movement that occurs from interdigitation. In deciding how elastics should be
used, the following factors should be taken into account:

• the size and material of archwire being used

• the size and strength of the elastics
• the direction of pull of the elastics or their wear pattern
• how long the elastics should be worn each day
the presence and location of bite ramps or pads

Much of the development of these concepts has come from Tom Pitts, Stuart Frost and Jeff Kozlowski.

Early archwires are very light and the elastic force needs to be matched to these so as not to overpower them.
Initial elastics are therefore 2 oz.

Light Medium Medium/heavy Heavy Extra heavy

2 oz/60g 3 oz/85g 4 oz/100g 5 oz/130g 6 oz/170g
3/16” Quail Otter Rabbit Kangaroo Impala
1/4" Owl Seal Fox Bear Ram
5/16” Parrot Dolphin Penguin Zebra Moose

Table 9.2: Intraoral elastic sizes and strengths commonly used in orthodontics. The names of the elastics are those used by Ormco
but the table can be repopulated to cover other manufacturer’s ranges

For example the protocol for a class 2 deep bite case would be as follows:
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Wire Elastic size Elastic pattern Duration Disclusion

0.014” CuNiTi Quail 3/16” 2 oz Short class 2 L6-U4 Fulltime Anterior ramps
0.018” CuNiTi Quail 3/16” 2 oz Short class 2 L6-U4 Fulltime Anterior ramps
Anterior ramps
0.014” x 0.025” CuNiTi Quail 3/16” 2 oz Short class 2 L6-U4 Fulltime (Add to ramps as
required)
0.018” x 0.025” CuNiTi Parrot 5/16” 2 oz Class 2 Reverse V Correct to edge-to edge Progressively reduce
L6-U3-L4 and hold for 3 months; ramps as overbite is
then night times only controlled
Kangaroo 3/16” 5 oz Full class 2
0.019” x 0.025” SS Full time if still class 2 Remove ramps
Impala 3/16” 6 oz L6-hook on upper archwire

For a class 1 open bite, the protocol would be as follows:

Wire Elastic size Elastic pattern Duration Disclusion

Rainbow Posterior pads and
0.014” CuNiTi Parrot 5/16” 2 oz Fulltime
LR2-UR1-UL1-LL2 muscle exercises
Rainbow Posterior pads and
0.018” CuNiTi Parrot 5/16” 2 oz Fulltime
LR2-UR1-UL1-LL2 muscle exercises
Rainbow Posterior pads and
0.014” x 0.025” CuNiTi Parrot 5/16” 2 oz Fulltime
LR2-UR1-UL1-LL2 muscle exercises
Fulltime if bite still open
Progressively reduce
Correct to normal
Dolphin 5/16” 3 oz or Rainbow pads as overbite is
0.018” x 0.025” CuNiTi overbite and hold for 3
Parrot 5/16” 2 oz LR3-UR1-UL1-LL3 reduces but continue
months; then night times
muscle exercises
only
Fulltime as required
0.019” x 0.025” SS Rainbow Correct to normal Remove pads but
Dolphin 5/16” 3 oz or
0.017” x 0.025” TMA Lower R hook-UR1-UL1- overbite and hold for 3 continue muscle
Parrot 5/16” 2 oz
when corrected Lower L hook months; then night times exercises
only

Elastic patterns
• full class 2
o from lower first or second molar to hook on upper archwire
• full class 3
o from upper first or second molar to hook on lower archwire
• short class 2
o from lower first molar to upper first premolar or
o from lower second premolar to upper canine
• short class 3
o from upper first molar to lower first premolar or
o from upper second premolar to lower canine
• class 2 reverse V
o from lower first molar to upper canine to lower first premolar
• class 3 reverse V
o from upper first molar to lower canine to upper first premolar
• rainbow
o from lower right lateral incisor to upper right central incisor to upper left central incisor to
lower left lateral incisor
• reverse rainbow (for class 3 cases)
o from upper right lateral incisor to lower right central incisor to lower left central incisor to
upper left lateral incisor
• posterior cross elastics
o as required but may involve multiple teeth; apply to all teeth in crossbite
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o can combine with a class 2 or class 3 component

• canine V
o from lower first premolar to upper canine to lower canine
• posterior V
o from upper first molar to lower first premolar to upper archwire hook

In general, use 2 oz elastics on round CuNiTi wires, 4 oz elastics on rectangular CuNiTi and 6 oz elastics on stainless
steel or TMA.

Developing a bonding plan

The six decisions above constitute the bonding plan. The bonding plan is best developed from careful clinical
observation, digital photographs, radiographs and study models if available. Torque selection for anterior
brackets should be done prior to bonding.

Five aesthetic features to check before Appointment 4

• smile arc development
• buccal corridors
• gingival display changes
• incisor axial inclination
• canine and buccal segment axial inclination

Five occlusal features to check before Appointment 4

• bracket height and alignment
• levelling and overbite correction
• antero-posterior correction
• transverse development
• arch coordination and interdigitation

Appointment 4 - photo/pan/repo appointment

About four weeks after placement of the 0.018” x 0.025” archwire, schedule a bracket repositioning appointment
with a new orthopantomogram (may not be necessary) and some up to date digital photographs of the occlusion.
Use this appointment to review torque selection as well as first and second order bracket position. In addition,
review need for further tooth reshaping. This represents the end of the first stage of finishing.

Six features to finish

• check CR=CO
• check full correction achieved
• check interdigitation and arch coordination
• final adjustment of tooth shape and size
• gingival shape adjustment
• finishing elastics required?

Myofunctional therapy
The forces that move teeth can either come from:
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• the archwires
• elastics
• the muscles (lips, cheeks, tongue, masticatory, respiratory)

While there is a wealth of information about archwires, and to a lesser extent about elastics, much less seems to be
written about the effect of muscles although orthodontists routinely harness their effects through the use of
functional appliances. The influence of muscles plays a significant role in the aetiology and treatment of anterior
open bites. Soft tissues are difficult to analyse, difficult to treat and difficult to monitor during treatment and
myofunctional therapy is often seen as a fringe or alternative therapy by mainstream orthodontics. It is a poorly
researched and understood field where measurement and compliance are difficult and success is variable.
Nevertheless, it is perhaps worth revisiting.

However, Etsuko Kondo’s book, Muscle Wins! Treatment in Clinical Orthodontics is worth diligent study. It focuses
on the ‘functional recovery of abnormal tongue, perioral muscle, chewing and cervical muscle activities, as well as
respiration, in correcting malocclusion’. In the paper by Kondo and Aoba (2000), two cases are presented,
successfully treated by myofunctional therapy and orthodontics, which many orthodontists would believe are
only manageable by orthognathic surgery.

Nasal respiration
The importance of nasal respiration for the proper development of the lower face has been commented on. The
effects of nasal restriction and therefore a change to oral breathing have been suggested as underdevelopment of
the maxilla in the transverse and sagittal planes as well as an increase in lower facial height.

Yoga exercises can be used to help patients change to oral respiration. The subject should be either lying down
or sitting and should inhale and exhale deeply and regularly using nasal respiration; the ratio of the time spent in
inhalation and exhalation should be 1:2. Starting off with a minimum inhalation time of four seconds, this can be
built up to an inhalation time of 16 seconds in adults. Once this has been mastered, a retention phase can be
added; the ratios now become 1 (inhale): hold breath (4): exhale (2) – so for a 4 second inhale, retention is 16
seconds and exhalation 8 seconds.

Tongue thrusts
Alexander (1999) has described a simple series of exercises can be taught to patients with a tongue thrust.

The first stage is to position the tongue in the palate so that it is just about to produce a “click.” This position can is
used as a reference to the proper tongue position when the patient swallows. The tongue is then held in this
position and the tip of the tongue forced upwards. This retrains the tongue muscles and should be done in sets of
10, three times a day. Etsuko Kondo has described a similar exercise where patients are asked to flatten chewing
gum into the vault of the palate.

The second exercise is called the “3-S’s”: slurp, squeeze, and swallow. The patient is asked to collect saliva, which is
the slurp; bring the teeth together and activate muscles of closure, the squeeze; and lastly, with the tongue in the
click position, the patient swallows. It is suggested that molar pads are fitted to the first and second molars when
using the squeeze exercise.

Huang et al (1990) have demonstrated the effectiveness of tongue spurs in controlling tongue thrusts and hence
closing anterior open bites. This has a small sample but those that were treated had a positive success rate which
was maintained at least one year after appliance removal. We have tried tongue cribs and there is no doubt that
they work but:

• not all patients find them comfortable

• they require the use of molar bands at a time when most cases are fully bonded
• if myofunctional therapy was as effective, then this would be the preferred method of treatment
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Ortho Technology’s Tongue Tamers (McRae EJ 2010) are a neat bondable solution to tongue spurs and eliminate
the need for molar bands.

Summary
There is a lack of both reliable clinical anecdote and research in this area. At the moment, success may be
achieved but we are never quite sure why, nor are we able to predict in which patients it may occur. Nevertheless
it shows promise which is worth further investigation regardless of how difficult that may be. It may that we need
to determine what intervention, in what circumstances, produces a successful outcome.

References
Alexander CD (1999)
Open bite, dental alveolar protrusion, Class I malocclusion: A successful treatment result
American Journal of Orthodontics and Dentofacial Orthopaedics 116: 494-500
Huang GJ, Roberto Justus R, Kennedy DB, and Kokich VG (1990)
Stability of anterior openbite treated with crib therapy
The Angle Orthodontist 60: 17-24
Kondo, E (2008)
Muscle Wins! Treatment in Clinical Orthodontics
Seoul, DaehanNarae Publishing Inc
Available from www.musclewins.com
Kondo E and Aoba TJ (2000)
Nonsurgical and nonextraction treatment of skeletal Class III open bite: its long-term stability
American Journal of Orthodontics and Dentofacial Orthopaedics 117: 267-287
Kozlowski J (2008)
Honing Damon System mechanics for the ultimate in efficiency and excellence
Clinical Impressions 16: 24-28
Downloaded from http://www.ormco.com/index/ormco-education-clinical-impressions
Accessed 21 January 2012
McRae EJ (2010)
Bondable lingual tongue spurs to treat anterior open bite
Master's Theses (2009 -). Paper 25. http://epublications.marquette.edu/theses_open/25
Accessed 21 January 2012
Pitts TR (2009)
Begin with the end in mind: bracket placement and early elastics protocols for smile arc protection
Clinical Impressions 17: 4-15
Downloaded from http://www.ormco.com/index/ormco-education-clinical-impressions
Accessed 21 January 2012
Thomas WW (2009)
Variable torque for optimum inclination
Clinical Impressions 17: 21-29
Downloaded from http://www.ormco.com/index/ormco-education-clinical-impressions
Accessed 21 January 2012