Basics of Sliding Mechanics

Basics of Sliding Mechanics

by Prof. Dr. Andrea Wichelhaus

Klinik fr Kieferorthopdie und Kinderzahnmedizin der Universitt Basel

Copyright Prof. Dr. Andrea Wichelhaus

Basics of Sliding Mechanics 1. Introduction

In the last 30 years there have been many new innovations which have influenced treatment strategies and in particular the treatment time. Until the introduction of the Andrews Straight-Wire Appliance in the 1970s fixed appliance therapy, standard edgewise brackets were commonly used for fixed appliance therapy. These were available as single or twin brackets. In this technique the bracket slot was maintained at a constant angle of 90 to the bracket base. In order to reach treatment goals the orthodontist had to introduce 1st, 2nd and 3rd order bends into the arch wires. 2. The edgewise appliance

One must distinguish between three types of edgewise brackets (Andrews 1991): 2.1.1 Non programmed system The same bracket is used for all teeth and has no 1st, 2nd and 3rd order bends incorporated into the bracket. This system relies on the orthodontist to achieve treatment goals for individual tooth positions by manually adjusting the wire angulation to produce permanent bends in the wire. 2.1.2 Part pre-programmed system These brackets are not fully programmed but reduce the amount of wire bending compared with non-programmed systems. 2.1.3 Fully programmed system The concept fort these brackets is that the 1st,2nd and 3rd order bends are integral to the bracket such that a straight wire can be used and a predetermined position of individual teeth achieved. There is a difference between sliding and non-sliding mechanics brackets. The difference is in the angles incorporated to compensate for 2nd order bends and rotations and can be split into three different groups: 1. Minimal translation brackets for extraction space of 0, 5 to 2mm. 2. Medium translation brackets for extraction space of 2,0 mm to 4,0 mm 3. Maximal translation brackets for extraction space of greater than 4,0mm 3. The Straight wire Appliance

The Straight wire appliance, a fully programmed edgewise appliance was patented by A-COMPANY, a division of Johnson & Johnson Company, San Diego, CA., USA, (Andrews 1991).

Basics of Sliding Mechanics

4.

The concept of straight wire described by Lawrence F. Andrews

The following list outlines the principle features of an individualised pre-programmed system. (Andrews 1991): 1. Each tooth type is considered to be the same between individuals. 2. Crown size has no direct influence on the optimal angulation and inclination of the tooth or on the relative contours of the labial surface of the crown. 3. The majority of individuals have "normalteeth irrespective of whether a malocclusion is present or not. 4. In order for the teeth to be brought into a correct relationship with one another the jaw size and the relation of upper to lower jaw must be normal. 5. In dentitions with normal teeth and correct jaw relationships an optimal occlusion can be reached. 6. When the teeth are positioned correctly the horizontal contact points of the bracket lies in at the same level or in the same plane. 7. The crown angulation (tip) measured from the most prominent ridge or groove on the labial surface is the same for all individuals with an optimal occlusion. (Fig 1). 8. The labio-lingual crown inclination (torque) is measured from a tangent which lies on the midpoint of each crown and parallel to the predominant labial ridge or groove is the same for all individuals with an optimum occlusion. (Fig 2). 9. Normal crowns have a similar facial contour when measured from the interdental embrasure to the most prominent labial point along the mid transversal plane for that dental arch (Figs 3+4). The interdental line is a constructed line running at the height of the middle of each crown through the broadest contact point for correctly positioned teeth.

Basics of Sliding Mechanics

Fig.1: Average crown angulation (tip) for teeth in the maxilla and mandible.

In order to apply these principles to treatment the Straight-Wire Appliance was designed so the bracket slot should lie across the intersection of the mid saggital and mid transversal planes. If the brackets are correctly placed the angulation of the slot initially is at odds with the plane of the dental arch. However with progressively larger arch wires which are arch shaped but flat the slots align and bring the teeth into the pre-programmed position according to the six keys of occlusion. (Andrews 1991).

Basics of Sliding Mechanics

Fig.2: Average labio-lingual crown inclination (Torque) for all teeth in both maxillary and mandibular arches.

Fig.3: Average prominence of the crown in the maxilla.

Basics of Sliding Mechanics

Fig.4: Average prominence of the crown in the mandible.

In contrast to standard edgewise the Straight-Wire appliance produces a better quality result in less time. The conventional mechanics and high forces used, in particular the use of large dimension steel archwires cannot be carried over to the new system. The use of excessive force by clinicians at the start of treatment leads to undesirable side effects: "Rollercoaster effect (vertical bowing effect) Increased overbite (bite deepening) Tipped and rotated canines and premolars in the extraction spaces

The initial euphoria diminished as it was found that it was necessary to make modifications to the system. Andrews and later Roth maintained the same forces and mechanics but altered the prescription of the brackets to help with the problems encountered; for example additional torque for the incisors and anti-tip and antirotation for canines, premolars and molars. Extraction or translation brackets were also introduced. This was marketed in the Roth developed system. The Straight-Wire appliance is therefore an individualised appliance where each bracket is tailored to the morphological and positional norms for each tooth type.

Basics of Sliding Mechanics

5.

The technical aspects of a straight wire bracket

Since the straight wire bracket contains all the pre-programmed prescription for the tooth and transmits that information via the wire to the tooth the following criteria must be fulfilled. 1. The bracket base must adapt well to the crown morphology. 2. The angulation of the bracket slot in the horizontal relates to the mesio-distal crown inclination or tip. 3. The thickness of the bracket to the slot base relates to the distance of the labial surface of the crown to the inter-dental line ( In/out) 4. The slot is also angulated with respect to the base in the vertical to bring about torque. (Fig. 5). The three types of edgewise brackets determine differences in construction (Andrews 1991): In non-programmed brackets in the standard edgewise technique the bracket bases are not specifically contoured and the base and slot are angulated the same for all teeth (Fig. 5). Part programmed brackets have different torque values in the slot but the bracket bases are the same as standard edgewise (Fig. 5). Only full programmed brackets have a contoured bracket base with built in torque so that the bracket slot runs parallel to the horizontal plane such that the mid point of the slot runs through the LA point (mid point of the clinical crown)(Fig. 5).

Fig.5: Bracket comparison Links: non-programmed bracket without inclination or contouring of the base. Middle: part programmed bracket with slot inclination but no contouring of the base. Right: fully programmed bracket with contouring of the base and angulation of the base

Basics of Sliding Mechanics

Fig. 6 shows the three different bracket types. The mid point of the base is glued to the LA point. It should be noted that only with the fully programmed brackets is the horizontal slot in line with the mid point of the crown. This is only possible because the base is contoured to the crown morphology but also angulated according to the correct crown inclination (torque) .Both of these point are prerequisites for a fully programmed bracket. (Fig.6) (Andrews 1991). If this is not the case a flat arch-wire will result vertical tooth movement as well as an altered inclination of the tooth.

Fig. 6: Comparison of bracket placement for the three types of edgewise brackets with the mid point of the bracket base overlying the mid point of the crown. Left: Non-programmed bracket the angulation and occluso- gingival position of the slot are incorrect. Middle: Part programmed bracket The occluso-gingival position of the slot is incorrect but the angulation is correct. 6. Right: Sechs Schlssel der normalen Okklusion and vertical positioning of the slot Fully programmed bracket Both angulation are correct. In the 70s Andrews broadened the definition of the Angle classification of malocclusion. Following an analysis of dentitions from 120 non orthodontically treated Patients with particular reference to crown morphology he statistically evaluated and presented the prerequisites for an optimal functional occlusion as "The six keys to normal occlusion(Andrews 1972).The basic criteria for the diagnosis of the occlusion were the long axis of the crown and the occlusal plane. 1. Molar relationship: The mesio-buccal cusp of the maxillary first permanent molar lies in the buccal groove between the mesio-buccal and disto-buccal cusps of the mandibular first permanent molar. The mesio-lingual cusp of the upper molar lies in the central fossa of the lower molar. The upper molar must be tipped so that its distal surface contacts the mesial surface of the lower second permanent molar (Andrews 1972). 2. Mesio-distal crown angulation (Tip): In a normal occlusion the gingival portion of the long axis of the crown lies distal to the occlusal portion of this axis. Each tooth has a characteristic amount of Tip.

Basics of Sliding Mechanics

10

3. Labio-lingual crown inclination (Torque): The angle between a tangent to the middle of the labial crown surface and a line drawn at right angles to the occlusal plane defines the 3 keys. If the crown is more lingual in the gingival section the value is plus and in the opposite direction negative. The upper central incisor has a value of 7 for the angle between the tangent and the line at right angles to the occlusal plane. The angle between the long axis of the crown and the tangent to the crown is 18 (torque). Crown torque for the lower incisors is -1. The angle between the long axis of the crown and the tangent to the crown is 16. For a normal occlusion the inter-incisal angle between the tangents to the crown of both upper and lower incisors is 174, although the inter-incisal angle between the long axes of the two crowns is on average 139 (Andrews 1972). 4. Tooth rotation An ideal occlusion can only be achieved if no rotations are present since rotated molars and premolars require more space although rotated incisors require less space. 5. No spacing For normal occlusal relationships with no tooth abnormalities and no discrepancies in arch length between the jaws the teeth should have tight contact points. 6. Curve of Spee A normal occlusion according to Andrews 1972 should have a flat occlusal plane in the lower jaw with a curve of Spee of not more than 1, 5 mm. A pronounced curve of Spee leads either to a space deficiency or excessive space in the respective arch.

Basics of Sliding Mechanics

11

7.

Comparison of tip und torque for 3 different bracket systems

The following table (1) shows clearly the different prescriptions for root torque and Tip depending on the mechanics used for three commonly used bracket systems. The values for the Andrews system is based on non-extraction treatment and this can be compare to the two extractions systems, namely the Roth system which includes over correction in the brackets and the MBT system introduced by McLaughlin, Bennett und Trevesi which has been modified specifically for sliding mechanics (Bennett & McLaughlin 1993).
Tab.1: Comparison of tip und torque for Andrews, Roth und MBT bracket systems.
Roth Maxilla Central incisor Lateral incisor Canine 1.Premolar 2. Premolar 1. Molar 2. Molar Mandible Central incisor Lateral incisor Canine 1.Premolar 2. Premolar 1. Molar 2. Molar Tip 5 8 13 0 0 0 0 Tip 0 0 5 0 0 0 0 Andrews Tip 5 9 11 2 2 5 5 Tip 2 2 5 2 2 2 2 MBT Tip 4 8 8 0 0 0 0 Tip 0 0 3 2 2 0 0 Roth Torque 12 8 - 2 - 7 - 7 - 14 - 14 Torque - 1 - 1 - 11 - 17 - 22 - 30 - 30 Andrews Torque 7 3 - 7 - 7 - 7 - 9 - 9 Torque - 6 - 6 - 11 - 17 - 22 - 30 - 35 MBT Torque 17 10 -7 -7 -7 -14 -14 Torque -6 -6 -6 -12 -17 -20 -10

Basics of Sliding Mechanics

12

Sliding mechanics
The main advantage of the straight wire system is the simplicity of the system because after the levelling phase all bracket slots lie in the same plane. This configuration permits sliding mechanics or movement of groups of teeth. In extraction cases the space closure is carried out using active tiebacks where a retraction force is applied from a soldered or crimped hook on the archwire to the hook on the molar attatchment of either first or second molar. An elastic module combined with a metal ligature (Fig 28) is stretched to double its original size and applies a defined force to the archwire and teeth. An elastic chain or elastic (Fig 28) can also be used but requires good cooperation and can impede oral hygiene. A 2-3 mm activation of a tie back elicits a force of 100 to 150 g Kraft. Assuming that the teeth have been correctly levelled this technique allows the use of lower forces and controlled tipping of the teeth during space closure. Excessive use of force causes the wire to deflect and tooth movement ceases. Recent developments have allowed the use of SE NiTi springs with a defined force plateau to also be used (Fig.29). For greatest efficiency a .019 x .025rectangular steel wire should be used in an .022slot. This wire provides good rigidity whilst allowing the wire to slide through the slots. The wire can be rounded in the buccal segments to improve the sliding in this area.

Abb.28: Elastic Tiebacks. Upper left: tie back attached to molar hooks for space closure. Upper right: Module attached to soldered hooks on the wire. Lower left: Elastic alone attached between the hooks. Lower right: Elastic chain alone attached between the hooks. Bennett / McLaughlin: Kieferorthopdische Behandlungsmechanik mit der vorprogrammierten Apparatur 1994

Basics of Sliding Mechanics

13

Fig.29: Tie back with coil spring. Samuels et al. 1993

The following advantages and disadvantages of straight wire mechanics for space closure are outlined: The advantages of sliding mechanics with straight wires and pre-programmed brackets: Minimal arch wire bending therefore quicker. Better sliding of the wire through the slots. Reactivation simple and not dependent on space. Disadvantage of sliding mechanics: Tendency to over activate elastics. Not sufficient time for teeth to upright if excessive force is used. The following factors restrict the efficiency of the straight wire technique. Incomplete levelling which resists distal sliding of the wire. Additional posterior torque in the wire tips the arch. Obstruction of the end of the wire with a ligature. Soft tissue resistance or gingival swelling in the area of space closure. Resistance from the cortical bone in the extraction area. Excessive force resulting in tipping of the teeth and binding of the archwire. Insufficient force. Treatment mechanics with the straight wire technique There are 2 treatment modalities with straight wire: 1. Space closure is required following extractions or 2. Alignment of teeth positioned outside the arch. The first modality requires a force application in a mesio-distal direction

Basics of Sliding Mechanics

14

In the pre-programmed 022system the .019x .025archwire is most effective. Alternatively a round steel wire (.020) or smaller dimension rectangular wires can be used, however these give less torque control and control of the overbite due to their lower stiffness. Traditionally hooks are soldered or crimped onto the arch wire in both arches. Wires manufactured with hooks included are commonly used with the following inter hook distance. Maxillary arch: 35, 38 und 41 mm. Mandibular arch: 24, 26, 28 mm. The force for space closure is applied with tiebacks or coil springs. For this purpose the elastic is stretched by 2 to 3 mm to achieve space closure of 1 mm per month. Treatment of high angle cases with weak masticatory muscles is generally faster than patients with hypo divergent maxillo-mandibular plane angles (low angle case). Normally one replaces the elastic every appointment. Forces can be applied buccally or palatally, both at the same time, or alternating to assist in space closure. In a study by Samuels et al. in 1993, a comparison was made between space closure with elastic modules versus with NiTi coil springs. Successful space closure on .019x .025steel wires with crimped hooks in both jaws was examined in 17 Patients. On one side of the arch I both jaws, a 150 g GAC Sentalloy medium coil spring was used and on the other side an elastic module from Unitec activated 2 to 3 mm to give an initial force of 400 to 500 g. During space closure six anterior teeth were retracted against the second premolars and first molars. The study showed that the rate of space closure was significantly faster and more uniform with the NiTi coil spring. The coil spring produced space closure at 1, 2 mm per Month in contrast to the elastic module at 0, 7 mm. In a further study in 1998 carried out on 18 patients it was shown that the rate of space closure was related to the level of force applied. They found that the 100 g Sentalloy Nickel Titan spring (Light) closed space at 0.16 mm/ week; the 150 g spring (medium) at 0.26 mm/week und the 200g (heavy) spring at .24 mm/week. The elastic module resulted in 0.19 mm of space closure per week. There was no significant difference between the 150 g and 200 g NiTi springs. Figure 30 shows graphically the relationship between the amount of space closure relative to the method and amount of force applied and time.

Fig. 30: Regression line. Graphic presentation of the rate of space closure (mm) related to different modules of force. Samuels et al. 1998

Basics of Sliding Mechanics

15

If space closure is faster than 1, 5 mm per month Bennett und McLaughlin have shown a loss in anterior torque and upright incisors at the end of space closure. During orthodontic space closure with sliding mechanics there is always friction between the archwire and bracket slot which reduces tooth movement. From canine retraction and throughout space closure, friction affects tooth movement. Various physical and biological parameters such as archwire dimension, wire quality, methods of force application, bracket design, ligature material, location of the resistance centre, viscosity of the saliva, corrosion and calculus or deposits in the slot reduce the effectiveness of the sliding movement. Schumacher et al.found that friction accounted for up to 50% of the loss of force. Due to the numerous factors affecting friction it is difficult to precisely determine the force used. It has to be remembered that this force also acts on the anchorage unit. A study from Ziegler und Ingervall showed that a friction free retraction of the canine with an individually constructed retraction spring produced less tipping and was faster than sliding mechanics with a class I elastic.

Bracket placement
The original edgewise brackets were positioned using a bracket height guide (see appendix). Individual crown shape was not considered. 1st order (in/out), 2nd order (tip) and 3rd order bends (torque) were bent into the wire for each patient. By the end of treatment the correct position of the teeth was established. This technique for positioning the brackets cannot be used with pre-programmed brackets. Pre-programmed brackets function according to individual tooth morphology. Forces and torsional movements are three dimensional. Consequently a standard reference point is no longer appropriate. This is clear when one considers that teeth come in different sizes.

Fig. 31: The influence of bracket position with pre-programmed brackets using a defined reference point of 5mm for both large and small teeth, Different torque values result. (Bennett, McLaughlin 2002)

Basics of Sliding Mechanics

16

Using a bracket height of 5mm for both small and large teeth the point of application of the force on the crown varies. (Fig.31) results in different torque application. Andrews defined the middle of the clinical crown as the correct place to position the brackets in order to achieve the correct torque and in/out values.

Bracket placement in the straight wire technique Following clinical investigations of 120 untreated patients by Bennett und McLaughlin in 1995, they developed a system to simplify bracket placement. Their findings are shown in Figure 32.

U7 3.05 0.64 5.16 1.79 L7 3.05 0.49 4.37 1.79

U6 3.20 0.62 4.96 1.98 L6 3.22 0.50 4.76 1.98

U5 3.41 0.59 4.96 1.98 L5 3.58 0.52 5.56 2.38

U4 3.98 0.62 5.95 2.38 L4 4.13 0.52 5.95 3.18

U3 4.91 0.68 7.14 3.18 L3 4.75 0.71 7.94 2.78

U2 4.37 0.64 6.35 2.98 L2

U1 5.18 Mean 0.63 Stan. dev. 6.95 Maximum 3.57 Minimum L1 4.11 0.63 6.75 2.58 4.25 Mean 0.65 Stan. dev. 7.54 Maximum 2.78 Minimum

Abb. 32: Durchschnittliche halbe klinische Kronenlnge bei 120 Fig.32 Average half crown length for untreated patients (Bennett, McLaughlin 1995).

The results showed that in fact an average value can be taken with the S.D lying between 0.49 und 0.69 mm. From these results an average theoretical value can be obtained. (Fig.33).

Basics of Sliding Mechanics

17

U7 4.0 3.5 3.0 2.5 2.0 L7 4.0 3.5 3.0 2.5 2.0

U6 4.0 3.5 3.0 2.5 2.0 L6 4.0 3.5 3.0 2.5 2.0

U5 4.5 4.0 3.5 3.0 2.5 L5 4.5 4.0 3.5 3.0 2.5

U4 5.0 4.5 4.0 3.5 3.0 L4 5.0 4.5 4.0 3.5 3.0

U3 6.0 5.5 5.0 4.5 4.0 L3 6.0 5.5 5.0 4.5 4.0

U2 5.5 5.0 4.5 4.0 3.5 L2

U1 6.0 5.5 5.0 4.5 4.0 L1 5.0 4.5 4.0 3.5 3.0 5.0 4.5 4.0 3.5 3.0 +1.0mm +0.5mm Average -0.5mm -1.0mm +1.0mm +0.5mm Average -0.5mm -1.0mm

Fig. 33: Theoretical calculated average values for bracket placement (Bennett, McLaughlin 1995).

Evaluation of clinical cases which were treated to Andrewss six keys of occlusion using the straight wire concept resulted in the following deviations from the mid clinical crown to the Andrews line. Maxilla: 1. The premolars were 0,5mm more occlusal. 2. The 2nd molar was 0.5-1 mm more gingival. Mandible: 1. The canine was 0.5 mm more gingival. 2. The 1st molar was 0.5 mm more gingival. In order to ensure good treatment results which adhere to the six keys of occlusion the following recommendations for bracket positioning for sliding mechanics were made. (Fig.34):

Basics of Sliding Mechanics

18

U7 A B C D E 2.0 2.0 2.0 2.0 2.0 L7 A B C D E 3.5 3.0 2.5 2.0 2.0

U6 4.0 3.5 3.0 2.5 2.0 L6 3.5 3.0 2.5 2.0 2.0

U5 5.0 4.5 4.0 3.5 3.0 L5 4.5 4.0 3.5 3.0 2.5

U4 5.5 5.0 4.5 4.0 3.5 L4 5.0 4.5 4.0 3.5 3.0

U3 6.0 5.5 5.0 4.5 4.0 L3 5.5 5.0 4.5 4.0 3.5

U2 5.5 5.0 4.5 4.0 3.5 L2

U1 6.0 5.5 5.0 4.5 4.0 L1 5.0 4.5 4.0 3.5 3.0 5.0 4.5 4.0 3.5 3.0 +1.0mm +0.5mm Average -0.5mm -1.0mm A B C D E +1.0mm +0.5mm B Average C -0.5mm D -1.0mm E A

Fig. 34: Recommended bracket position for sliding mechanics (Bennett, McLaughlin 1995).

Common mistakes in bracket placement Horizontal errors Horizontal inaccuracies occur usually in the buccal segments and in particular with the 2nd premolars because the clinical crown is often not fully erupted. Smaller bracket bases preferred for aesthetic reasons also increase the chance of inaccuracy. The consequences are: Mesial tooth rotation Distal tooth rotation Compensation: Control the bracket position from the occlusal with a dental mirror.

Basics of Sliding Mechanics

19

Fig. 35: Checking the horizontal bracket position on the premolar with a dental mirror (Wichelhaus 2006)

Axial errors Use of rhomboid bracket bases can lead to axial errors as it can not be used as a reference point. Vertical lines etched into the bracket base assist in positioning. Furthermore variations in root geometry can lead to axial errors. The consequence of false axial positioning are: Incorrect root angulation

Compensation: Observe the root position on an OPT prior to bonding.

Fig. 35: OPT of a patient before and after orthodontic therapy. The atypical root geometry of tooth 12 was not noticed when placing the brackets (Wichelhaus 2006)

Basics of Sliding Mechanics

20

Vertikal errors According to Andrews the brackets should be sited over the mid point of the long axis of the clinical crown .Vertical errors can be caused by: 1. Partially erupted teeth 2. inflammed gingiva 3. buccally tipped teeth 4. lingually tipped teeth 5. crown fracture after trauma The consequences are as follows: 1-3. In these cases the brackets are too occlusal or incisal (Fig.36).

Fig. 36: The clinical crown appears shorter with proclined. Hence the bracket is too occlusal (Bennett, McLaughlin 2002).

4 und 5. In these cases the brackets are too gingival (Fig.37).

Abb. 37: The clinical crown appears longer with retro inclined teeth. Hence the bracket is too gingival. (Bennett, McLaughlin 2002).

Compensation: Measurement of the clinical crown prior to bonding especially where the teeth are severely inclined eg. Angle class II/1 und II/2. With fractured teeth estimate the correct clinical crown length. Lateral incisors are on average 10mm and central incisors 11 mm.

Basics of Sliding Mechanics

21

U7 3.50 3.80 L7 3.50 3.85

U6 3.75 3.75 L6 3.75 3.85

U5 4.00 3.85 L5 4.00 4.10

U4 4.25 4.30 L4 4.25 4.44

U3 5.00 5.30 L3 5.50 5.50

U2

U1 Source 1 Source 2

4.50 5.25 4.90 5.60 L2 L1 4.75 4.50 4.70 4.40

Source 1 Source 2

Fig. 38: The length of half the anatomical crown ( Woelfel 1990 und Kraus et al. 1969).

Archwire sequence for sliding mechanics:

1. 2. 3. 4. 5. 6. .016 Biostarter .016 Titanol Low Force .016 x .022 Titanol Low Force .016 x .022 Stahl .018 x .025 Stahl .019 x .025 Stahl

Levelling During levelling there are side effects in the vertical and transverse dimensions to be aware of. 1. Extrusion of the incisors At the end of treatment canines have a mesio-distal tip of 8 in the maxilla and 3 in the mandible. At the start of orthodontic treatment, canines are often upright (Fig. 39). The angulation of the slot leads to an extrusion of the incisors. (Fig. 40)

Fig. 39. Canines are often upright in a mesio-distal direction at the start of treatment (Wichelhaus 2006).

Basics of Sliding Mechanics

22

Fig. 40. An upright canine position at the start leads to an extrusion of the incisors (Wichelhaus 2006).

In the majority of cases incisor extrusion is not wanted and should be avoided as intrusion mechanics are not only complex but the treatment time is increased. The following techniques can be employed to avoid extrusion: a. Bypass the incisors until the canine is correctly mesio-distally angulated. (Fig. 41). The incisors are included on the arch wire once this has been achieved which avoids extrusion. Disadvantage: Inclusion of the incisors at a later stage means dropping back down to a smaller size wire which increases the treatment time by up to 3 months.

Fig. 41: Solving incisor extrusion during levelling. The incisors were not initially included on the archwire. (Wichelhaus 2006).

b. The levelling arch wire runs gingival to the incisor bracket giving an intruding force thus counteracting the extrusion forces. Disadvantage: Depending on the vertical position of the incisors the force is uncontrolled and excessive.

Basics of Sliding Mechanics

23

c. Bending of a step in the archwire mesial to the canine so that the wire lies passively in the incisor brackets. (Fig.42). Disadvantage: Bending aligning archwires requires a special electronic heating apparatus.

Abb. 42: Bend incorporated into the archwire (Wichelhaus 2006).

d. Bend in an exaggerated sweep in the levelling archwire with the Memory- Maker (Fig. 43). Advantage: There is no loss of time in the levelling phase as the incisors can immediately be aligned. Disadvantage: Not all wires can be programmed.

Fig. 43: Sweep bent into the wire with the Memory-Maker to avoid incisor extrusion. (Wichelhaus 2006).

2. Rotation and tipping of canines during canine retraction Canine retraction play san important role in orthodontics. In non extraction treatment the canine is less important because the saggital tooth movement is very little but in extraction cases especially with the Roth system the side effects are rotation, distal tipping and extrusion.

Fig 44: Side effects of canine retraction (Wichelhaus 2006).

Basics of Sliding Mechanics

24

These problems can be minimised bio mechanically if a large dimension wire is used. However the disadvantage is that the friction resulting from applied forces and moments in the saggital movement of the teeth is so large that little tooth movement occurs. Friction and optimal tooth movement are inter-related to one another by opposing eccentric forces. Retraction hooks are often too short because longer ones traumatise the gingival which leads to less favourable force application. To help with light canine retraction at the start of treatment lace backs are used (Bennett und McLaughlin 2002). These are .010 or .009 steel ligatures in a figure of eight running from the canine to the molar which hold back the canine crown whilst uprighting occurs and at the same time lightly retracts the canine.

Fig. 45: Lace back for canine retraction in the early phase of treatment.

When a lace back is recommended it is used at the same time as theTitanol Low Force wire which is fixed with steel ligatures. To reduce friction, the steel ligature is squeezed with a Weingart plier.

Steel wires The steel wires must be individualised to the patients own dimensions from the start models. 1. Correcting the transverse dimensions (Fig. 46,47 (Wichelhaus 2006))

Basics of Sliding Mechanics

25

3er-Spitze

Bukkale Hckerspitzen

Richtung Zentralfissur 7er

Symmetry (Fig.48)

Harmonising (Fig.49) The archwires must be co-ordinated to one another so that good interdigitation of the occlusion is possible. This applies even if additional bends are put in the wire.

Bogenkoordination Ober- und Unterkiefer

Basics of Sliding Mechanics

26

To ensure good co-ordination it is better to change upper and lower archwires at the same time. During space closure premature contacts can affect space closure. 2nd order bends Vertical control of the incisors is ensured by bending sweep into the wire which runs distal from the canines to the second molar. 3rd order bends It is essential to control the torque of the incisors in orthodontic therapy. Additional torque may be required and in particular palatal root torque for the upper incisors and labial root for the lower incisors (Fig.50).

Fig.50: The majority of patients treated with sliding mechanics need additional palatal root torque in the maxilla and labial root torque in the mandible (Bennett, McLaughlin 2002).

Correct incisor inclination supports the occlusion in the saggital and produces a good aesthetic result. Although the Bennett und McLaughlin bracket system incorporates in the maxilla has 17 incisal palatal root torque and in the mandible -6 lingual crown, this is still insufficient in many cases. Additional torque is often needed in the following patients: Angle Class II/2 During the levelling phase the axial inclination of the upper incisors often changes through labial crown movement rather than palatal root torque (Fig. 51).

Fig.51: Insertion of an aligning archwire in Angle Class II/2 causes proclination of the crown. (Wichelhaus 2006).

Basics of Sliding Mechanics

27

In view of the hyper tonus of the perioral muscles in many cases it can be seen from cephalometric analysis that the incisor position relapses if the crowns are proclined.Therefore the following modifications to the sliding mechanic technique are recommended. 1. Intrusion of the incisors 2. Compound archwire:.018x.025 with 45 torque(Fig.52) 3. Levelling

Fig.52: Torque application prior to levelling in Angle class II/2 (Wichelhaus 2006).

The initial intrusion and torque can result in unwanted side effects: a. Extrusion of the posterior teeth b. Labial crown torque Angle Class II/1 and extraction therapy Despite increased torque values for the incisors in the Bennett und McLaughlin brackets these are insufficient during overjet reduction and the incisors may become retroclined. This tendency is worsened if high forces are used during retraction. Today force control is easily controlled if super elastic springs are used. NiTi coil springs with a force of 1,5N are recommended. Prior to overjet reduction the following must be completed. 1. Intrusion To avoid contact of the upper incisors with the lower incisor brackets during retraction of the upper incisors, the overbite must be fully reduced. The decision on whether to intrude upper, lower or all incisors is based on aesthetic and functional considerations. 2. Torque Before retraction the axial position of the incisors must be assessed using the torquing key (Forestadent). Additional radiographs are not necessary.Torque can be applied with: Compound archwire : .018 x.025 with 45 torque .019 x .025 Stahlbogen with 20 torque The following clinical situations must be differentiated. 1. Space closure in the lower arch is complete. (Fig. 53). In this phase no intermaxillary elastics are used and control of torque in the upper incisors is essential.

Basics of Sliding Mechanics

28

Fig. 53: Torque control in Angle class II/1 with extractions prior to overjet correction (Bennett, McLaughlin 2002)

2.

Space closure in both arches (Fig 54). In this clinical situation the lower molars must be brought forward using additional intermaxillary elastics. There is a risk of proclining the lower incisors and therefore additional labial root torque necessary.

Fig. 54: Torque control in Angle class II/1 with extractions prior to overjet reduction. (Bennett, McLaughlin 2002)

Note: After adjusting the archwire in all three dimensions, the .019 x .025 steel archwires should remain in the mouth for 2 months to allow them to become passive and fully express the torque and levelling effects. Only then is space closure commenced so that friction is reduced.

The use of intermaxillary elastics during space closure has the following side effects: (Fig. 55): Mesial rotation of lower molars Mesial tipping of lower molars Extrusion of lower molars Proclination of lower incisors Extrusion of upper incisors Torque loss in the lower incisors Retrusion of upper incisors Tilting of the occlusal plane

Basics of Sliding Mechanics

29

Fig. 55: Side effects of class II elastics (Wichelhaus 2006).

The following methods can compensate for these effects: Only use elastics on .019 x .025 steel wires Sweep in the upper archwire Torque in the upper archwire Reverse torque in the lower archwire Uprighting mechanics for the lower molar Headgear to control the occlusal plane The following pictures show the sequence of treatment:

Basics of Sliding Mechanics

30

Figures: Patient with a deep bite and space problems in the buccal segments. She also presents with an Angle class II. (Wichelhaus 2006)

Extractions were planned to solve the crowding problem. fixed appliances were indicated to align the teeth and close space. Throughout treatment overbite control is essential.

Basics of Sliding Mechanics

31

Figures: patient in fixed appliance therapy. Sweep was incorporated into all the archwires used right from the start. (Wichelhaus 2006)

The mesial movement of the lower buccal segments were accomplished using sliding mechanics and class II elastics. Uprighting of the lower molar roots mesially was achieved with an uprighting spring. These extend mesial to the canines and support the intrusive effect of the lower archwire.

The additional use of a low pull headgear with long cranially angulated outer arms enhances the effect of the sweep and brings about a counter clockwise rotation of the occlusal plane.

Basics of Sliding Mechanics

32

Figures: Patient at the end of treatment with sliding mechanics. All teeth are aligned; the canines and molars are in a neutral occlusion. Despite extraction therapy the overbite has been successfully treated. (Wichelhaus 2006)

Basics of Sliding Mechanics

33

Appendices

Bracket distances according to Ricketts

3,5 3,5

4,0 4,0 4,5 3,5 4,0

4,0 3,5 4,5 4,0 4,0

3,5 3,5

4,0 4,0 4,0 3,5 3,5 3,5 3,5 4,0 4,0 4,0

Orthodontic forces in g

320

120 120 130 70

85

85

70

130 120 120

320

270

90

90 110

60

60

60

60 110 90

90

270

Basics of Sliding Mechanics

34

Symmetry card, torque control and sweep

Basics of Sliding Mechanics

35

Literature list Andrews, L.F.: Straight Wire. The Concept and Appliance L.A. Wells Co, San Diego, 1989 ISBN 0-9616256-0-0 Andrews, L.F.: Neuster Stand der Straight-Wire-Apparatur In: Mechanische und biologische Grundlagen der kieferorthopdischen Therapie Ernst Hsl, Anton Baldauf Heidelberg: Hthig, 1991 ISBN 3-7785-1959-X Andrews, L.F.: The six keys to normal occlusion. Am J Orthod 1972 (62): 296-309 Bennett, J.C. & McLaughlin R.P.: Orthodontic treatment mechanics and the pre-adjusted appliance. Wolfe Publishing, 1993 ISBN 0-7234-1996-X Bennett, J.C. & McLaughlin R.P.: Orthodontic management of the dentition with the pre-adjusted appliance. Mosby, 2002 Woelfel J B: Dental anatomy: its relevance to dentistry. Fourth edition. Philadelphia: Lea and Febiger, 1990 Kraus B S, Jordan R E, Abrams L: Dental anatomy and occlusion. The Williams and Wilkins Company, Baltimore, 1969