The Protocol Clinical Issue by OC Orthodontics

THE

PROT SPECIAL CLINICAL EDITION!

THE

PROT

TABLE OF CONTENTS

The 14 Keys to Pitts Case Management Dr. Tom Pitts & Dr. Duncan Brown

Active Early Principles

Active Early Concepts: Flipping & Flocking

Dr. Tom Pitts & Dr. Duncan Brown

Overcoming Challenges in PSL with “Active Early” and H4

Arch Form Evolution: The Esthetic Possibilities of the Pitts Broad Arch Form & Progressive Archwire Sequence

I.L.S.E.: Immediate, Light, Short, Elastics with Disarticulation

You Can Have It All

Dr. Tom Pitts & Dr. Duncan Brown

Dr. Tom Pitts, Dr. Duncan Brown, & Dr. James Morrish

“The 14 Keys to Pitts Case Management” “We are what we repeatedly do, excellence, then, is not an act but a habit” - Aristotle Introduction: How many times in your career have you come back from a course having seen and heard some wonderful things that you wanted to implement into your clinical procedures, only to find out when you got home that putting them into practice was very difficult. Very shortly, you reverted to old habits, and all the “value” you thought possible was lost. Inspirational speaker and self-help author, Tony Robins is correct when he says, “I know lots of people who know what to do, but fewer that do what they know”. Today’s orthodontic patients consistently demand more than “just straight teeth”. While “putting the plaster on the table” is now generally acknowledged as not being representative of the best orthodontics has to offer, the reality of everyday

practice confirms that esthetic decline is quite common with treatment1, and patients want treatment time to be a short as possible. For years I have tried to simplify diagnostic processes and case management strategies allowing the Orthodontist to attain greater consistency in delivering optimal esthetic and functional occlusal results. This requires that the Orthodontist expand his/her diagnostic and mechanical understandings beyond reliance on improved “straight wire” appliances to attain superior esthetic results. David Sarver has made great contributions by painting an accurate picture of todays desired facial and smile esthetics and the impact on esthetics of orthodontic treatment mechanics. I also agree with his concept on placing the position of the upper incisor

as the prime diagnostic criteria in developing superior esthetics2. Today I would like to develop the context for the pivotal role of case management in attaining superior esthetic and occlusal results, and suggest strategies for application of simple case management practices that provide consistent improvement in esthetic and functional outcomes during treatment.

The Pivotal Role of Case Management: Treatment planning is one of the milestones of every Orthodontist’s training. Large amounts of time and energy can be devoted to the evaluation of “static” records, like model analysis for crowding, cephalometric evaluation of potential growth direction, positions of the teeth

Initial Planning

Pitts Case Management Principles

Pitts Case Management

Contemporary Case Management Practices

Figure 1

The finest “artistic” orthodontic results are produced by the best case managers regardless of the appliances they use. This is because these clinicians clearly understand the technology they use on a daily basis, and apply clinical opportunities that are available to address specific patient clinical needs. In addition, these special orthodontists are not stymied by the “stability” ball and chain in their treatment protocols.

“Active Early” Case Management Core Principles: For years Orthodontists have desired to gain control of axial inclination earlier in the treatment cycle. However limitations imposed by the traditional application of “straight wire theory”, where torsion is created through incremental increases in wire dimension occur late (if at all) in the treatment cycle make it nearly impossible3. By using certain protocols, orthodontists are now able to remove that limitation. Applying appropriate levels of technology to an “artistic” end result creates many positive opportunities. If I want to “activate” the appliance and treatment as early as possible, I can use the SAP4 bracket position to adjust the vertical position of the incisors, invert groups of brackets to activate the appliance, select arch wire progressions that control axial inclination early in treatment, use arch forms that develop the posterior segments of the

arches sooner, implement “ELSE” (Early Light Short Elastics) to control forces, and appropriate disarticulation to encourage early “wanted” tooth movements. This is known as an “Active Early” approach to case management5. Clinicians have been trying to explain the “stages of clinical management” for years, usually without broad success. In our case management approach5 the treatment cycle is conceptualized as occurring in two stages based on clinical management opportunities available during the stage (Figure 2).

First Stage: Where either round or non-adjustable dimensional wires are used. The goal during the first “Active Early” stage of treatment is to achieve the majority of your occlusal and esthetic goals for the patient. Clinical management opportunities focus on adjustment in bracket position, adjustment of ELSE patterns, refinement of disarticulation, adjustment in tooth morphology with positive and negative coronoplasty, slenderizing, use of auxiliaries (TAD’s for example) to control anterior and posterior tooth movements and NMI (neuromuscular intervention) as appropriate. With our protocols, we now begin early arch width development,

Active Early

and skeletal bases, traditional “closed mouth” facial photographs for soft tissue positions, VTO’s for potential tooth movements, and mounted models for CO/CR discrepancies. Once a doctor has been in practice for a while, and comes to appreciate the dynamic aspects of patient care, the value of these “initial planning exercises” change, and value of sound case management practices comes into play (Figure 1).

leveling, torque control, AP and early vertical development. This stage lasts until the Pan/Repo appointment (PRACM). This is described by Dr. Jim Morrish of Bradenton Florida as Panorex Reposition, Adjust Case Management. In my experience, this commonly occurs around the 4th appointment, after some degree of torsion improvement and arch development in non-adjustable dimensional arch wires has been attained (Figure 4). At PRACM, adjustments in bracket position, bracket torque (upright/flipped), ELSE, disarticulation, need for tooth re-approximation, or a modification of mechanics (decision to extract, TAD placement, etc.), based on a definitive review of the case progress are made (Figure 5, 6). Most traditional orthodontics is taught on the basis of “sequential mechanics”, where one mechanical goal is addressed after the preceding goal is attained (transverse development, level/align, overbite correction, occlusal correction). One of the reasons I enjoy using a PSL appliance like H4 self-ligating bracket from OC Orthodontics, is that many of these clinical managements aspects can be approached “simultaneously”, resulting in significant gains in treatment efficiency. This “simultaneous mechanics” approach to addressing esthetic and functional treatment goals is a pivotal feature of “Active Early” (Figure 3). Significant occlusal gains in alignment, OB correction, and A/P correction, are combined with improvements in smile arc creation, transverse arch developments, and axial inclination improvement occurring quite early in the treatment cycle, usually by the 4th appointment. Another hallmark of “Active Early” is the continuous assessment of progress that is occurring towards both esthetic and functional goals as treatment progresses. I encourage the broad adoption of an

Stage 1

Early Tipping Mechanics

Non-adjustable Mechanics

Stage 2

Adjustable Mechanics

Finishing

Figure 2

orthoevolve.com // © ORTHOEVOLVE 2015

Second Stage: After PRACM, where adjustable dimensional wires are used, the goal is the refinement of the esthetic and occlusal aspects leading to optimal results most appropriate for the patient. Clinical management opportunities focus on overcorrection, AW adjustment for occlusion and esthetic refinement, tooth size adjustments for either esthetics or anterior/ cuspid guidance, optimization of the occlusion through occlusal adjustment (CO=CR), and refinement of mini-esthetics of hard and soft tissue.

The Goal: Better Results Through Simple Concepts, Trainable Skills My goal in clinical teaching has been to simplify complex concepts into contemporary treatment protocols that can provide significant advantages in the treatment of most orthodontic cases. While some features of a patient’s clinical outcome cannot be determined by orthodontics, many are able to be directly influenced by the Orthodontist. In an “Active Early” approach, I encourage clinicians to focus on the clinical opportunities they can control. In my experience I have identified several clinical approaches that positively affect the quality of the end result: “The 14 Keys to Pitts Case Management”. The next section will introduce some of these important concepts and clinical opportunities that Orthodontists can use to improve their clinical results. These will all be discussed more fully in subsequent “white papers”.

Use of “simultaneous” rather than “sequential” mechanics can lead to greater control and efficiency Early Tipping Mechanics

Non-adjustable Mechanics

Adjustable Mechanics

Finishing

Alignment Leveling and OB Correction A-P Correction Smile Arc Creation Transverse arch development and Torque Control Space Closure Finishing

Figure 3

PRACM - Read & React Milestone

Active Early

“every patient/every appointment imaging approach” as a discipline in improving continuous case progress assessment. The collateral marketing and patient education benefits of imaging are so great that even staff members who are initially concerned with the extra effort, are soon converted to raving fans! None of the clinicians I know that have adopted this discipline, have ever regretted the effort.

Active Early

Pitts Case Management

4 P Early Tipping Mechanics

R Non-adjustable Mechanics A C M

Figure 4

Incisor Display at Rest

Incisor Display on Smile

Transverse Smile Dimension

Resting Lip Support

Crowding

Smile Arc

Buccal Corridors

Gingival Display on Smile

Figure 5

Adjustable Mechanics

Finishing

Pitts Case Management 4 Appointments Incisor Display at Rest

Incisor Display on Smile

Transverse Smile Dimension

Resting Lip Support

Crowding

Smile Arc

Buccal Corridors

Gingival Display on Smile

Stage 1: the first of the 14 Keys to Case Management In a conventional “straight wire” approach to treatment, all early tooth movements involve tipping, and in most approaches very limited control is afforded to the Orthodontist. In contrast, in the “Active Early” approach a good deal of control is available through a number of clinical opportunities even when using non-adjustable wires. Most obvious among them are:

1. Positive and Negative Coronoplasty: Patients today want beautiful faces, beautiful smiles, and beautiful teeth; meaning teeth need to be “optimized” for shape and contour. Prior to bonding, esthetic re-contouring improves the ability to place brackets in the appropriate location to maximize the smile arc, optimize axial inclination, and control 1st and 2nd order changes during tipping or early torsion mechanics. Softening the cusp tips of the cuspids and first bicuspids, normalizing facial irregularities, and optimizing length/width ratios of the upper anterior teeth is critical to optimum bracket placement through either positive or negative coronoplasty. All surfaces that have been adjusted are smoothed with a white stone and black rubber tip using a high speed hand piece.

2. “SAP Bracket Position7” as a tool in gaining optimal esthetics: Bracket

Initial Smile Close Up

position is individualized to meet patient esthetic need. In patients with “flat” occlusal planes or those that require increased enamel display, the progression of the wire plane, created by bracket position, must increase to develop the smile arch by extruding the upper incisors relative to the upper bicuspids (Figure 7, 8). In patients with normal occlusal planes a more modest progression in the wire plane is still advisable to protect the smile arc as the upper arch broadens with treatment. A modest progression in still advised in deep bite cases to avoid excessive reduction in smile arc with reduction in overbite. It is important to remember that large bracket progressions in the upper arch must be compensated for by over-leveling the lower arch to establish optimum overbite relationships. A number of articles on the SAP technique have been published in recent years6,7,8 and SAP bracket positioning is now being employed regularly around the world.

3. “Bracket and Torque selection”, Why I love the H4 Passive Self-Ligation by OC Orthodontics: With practitioners attempting to treat more cases without

Progress Smile Close Up Figure 6

extractions, control of proclination of the upper anterior teeth has become a greater challenge. Frequently the technical challenge is getting enough lingual crown torque without having to resort to complex wire bending to attain esthetic results. “Low torque” Rx’s endorsed by some PSL bracket producers have not met these needs for me9. One of the reasons I prefer the H4 appliance is that the Rx is predictable when upright, and appropriate when flipped, providing greater lingual crown torque to the central when up-righting of the anteriors is required (Figure 9). When using “flipped” anterior brackets, we encourage the patient to be seen every 6-7 weeks to assess progress and palpate and the upper anterior alveolus. Once ideal axial inclination is attained, the appliance can be “deactivated” simply by reducing the arch wire dimension or adjusting the 3rd order bending. Note that it is important to use Beta Titanium arch wires no larger than 19x25 when using “flipped” appliances.

4. “ELSE” - Early, Light, Short, Elastics: I have advocated use of early light elastics for the past 20 years, especially when using PSL mechanics. Sabrina Huang, a close friend of mine from Taiwan, suggested the acronym some years ago, and I continue to describe the technique in those terms. The use of ELSE (no more than 2.5 oz.) increases the efficiency of treatment dramatically by maximizing “wanted” tooth movements in all dimensions, and minimizing or mitigating “unwanted” tooth movements during the tipping or early torsional phases of treatment. Patient cooperation is critical, and reinforcing early progress through “every appointment” photography is very useful. John Campbell describes the use of ELSE to his patients as, “24 hour elastic wear is not part of your treatment, it is your treatment”.

orthoevolve.com // © ORTHOEVOLVE 2015

Pitts Case Management SAP Bracket Position

5. “Disarticulation” - bite turbos, or occlusal pads as a tool in increasing effectiveness of ELSE: PSL mechanics are broadly appreciated as using minimal RTS (resistance to sliding), in conjunction with low forces. By encouraging “wanted” tooth movement and removing the forces of occlusion that perpetuate the malocclusion, disarticulation contributes to the effectiveness of early mechanics. Adjustment to the disarticulation is made when required. This eases TM joint loading.

6. Arch Wire Selection and Progression - as a tool in controlling axial inclination early in treatment: Traditional straight wire application relies on incremental increases in arch wire dimension to gradually develop 1st, 2nd, and 3rd order control. The reality is that this approach is not very effective, encouraging many to reconsider the basic premises of straight wire theory10. One of the distinguishing features of the “Active Early” approach is the adaptation to “slop” that is present in all straight wires appliances. Through tested case management practices, appliances, and wire selection we can now negate the adverse effects of “slop”. It has never made sense to me to start with arch wire forms that are narrower than the case needs to finish esthetically. Working with OC Orthodontics, we have created a full suite of arch wires that develop the arches transversely from the outset, through the whole of the buccal segments (Pitts Standard, Pitts Broad), where research has shown that a great amounts of transverse development occurs11 (Figure 10). In order to help early torque control, i2, i3 Leashes are used as a tool of controlling axial inclination early in treatment: The “rediscovery” by Daniela Storino and other believers of placing incisal “leashes” of elastomeric chain to minimize unwanted tipping of teeth during the relief of crowding is proving very helpful, especially in cases where the anterior brackets have not been “flipped”.

7. Patient Motivation - as a tool of controlling axial inclination early in treatment: Everything depends on the patient being a full partner in attaining their best

Figure 7

esthetic result. Whether it is 24 hour elastics wear, modification of sleep patterns, or doing “PT” exercises, it is important to educate the patient or their parents on their critical participation in the process. Larry White has correctly identified overall compliance as the “Achilles heel” of our profession12, and the inadequacy of traditional approaches to change that dynamic. It is critical to have a collaborative relationship with patients in their treatment, to celebrate what they have accomplished, and what their new “possible self” holds for them. This goes beyond “mere cooperation” and beyond the health benefits of orthodontics into the social and psychological benefits of treatment.

8. NMI - “neuromuscular intervention” as a tool in improving results: The control of habits and behaviors that may be detrimental to treatment progress is generally appreciated as critical. By intervening in noxious breathing patterns (SDB sleep disorder breathing, sleep apnea), and noxious muscular behaviors (lip hypotonicity, swallowing patterns, digital habits, lip biting, postural concerns, sleep patterns) the quality of treatment can be improved.

7 Months

9. “PRACM” - the critical “read and react” milestone: If adjustments to bracket position or major mechanics are required to bring the case to an esthetic conclusion, non-adjustable wires are replaced and Stage 1 clinical opportunities continued. If a significant number of brackets have been repositioned or “flipped”, it is usually wise to replace the same size non-adjustment wire for one treatment interval.

Stage 2 - Clinical Opportunities If the Stage 1 response to treatment has been favorable, Stage 2 adjustments are directed towards refining the occlusion and optimizing the esthetic result. There are a number of clinical opportunities available in Stage 2:

10. Arch Wire Adjustments - As a tool of controlling axial inclination, arch form, and transverse arch development: The “10 tooth smile” has represented the gold standard for dental ethics for years. Today many excellent students of dental esthetics prefer a “12 tooth smile” esthetically13, and I agree with them. Due to the fact that the arch form is directly related to the shape of the wire used and not the bracket system the orthodontist decides to use14, I do not use “standard arch blanks” but shape

4 Appointments Figure 8

Pitts Case Management H4 Torque Opportunities Torque U1 U2 Normal +12 +8 Flipped -12 -8 Torque Flipped Normal Flipped

L1 +6 -6

L2 +6 -6

U3 +7 -7

U4 -11

U5 -11

+7 -7

-12

-17

Figure 9

bendable arch wire to optimize posterior arch development for esthetics. Palpation of the buccal and lingual alveolar processes at each appointment is required to ensure that the patient’s “biological availability”5 is not compromised. Arch forms have tended to be too flat anteriorly, too broad through the cuspid and first bicuspid, and too narrow through the second bicuspid and molars. I found that bending of adjustable arch wires was unavoidable. I have worked with OC Orthodontics to produce arch forms that mimic a shape that provides superior esthetics; OC Orthodontics’s Pitts Standard and Pitts Broad arch forms. I typically use the “Broad” Arch form on all cases from the first bracketing. The only exception is when I have a narrow upper arch combined with a wide lower arch. Then I will use a “Standard” on the lower arch. Research has shown that as much posterior arch development occurs in round wires as occurs in dimensional arch wires21, and that is why the Pitts form is available in the same arch form for round, square, and rectangular wires. This feature facilitates an “active early” approach to transverse arch development with a greater degree of torsion control whether using familiar wire progressions or when using OC Orthodontics’s H4 appliance. Where unadjusted nickel-titanium or beta-titanium arches have not optimized axial inclination, the practitioner can use shapeable beta-titanium arches for minor corrections (Figure 11). Stainless steel wires are available, however in the “Active Early” approach, I usually only use stainless steel arch wires for extraction cases. We teach necessary posterior torque control in our courses.

11. “Overcorrection”: as a tool of controlling rebound: With it being generally conceded that permanent retention is a requirement of orthodontic stability, the role of “overcorrection” as a means of guiding the treatment result to a satisfactory conclusion has become more important. In our Masters training program, we spend considerable effort clarifying this complex challenge, but in essence it is advisable to overcorrect A/P, vertical, and transverse discrepancies for period of time, and then discontinue major mechanics as the occlusion adapts to the revised neuromuscular environment. With the improved tolerances of the H4 bracket system, I have found that there is less need for overcorrection of individual rotations.

12. “CO=CR”: as a tool in supporting long term joint health: I treat cases to CR whenever possible. There has been much discussion of how to best attain this goal. I have gravitated towards a Peter Dawson style approach15 for manipulating the mandible as something that is reproducible, relatively simple to do, and broadly applicable during the course of treatment. One important aspect of this technique is “bi-manual manipulation” of the mandible as a means of disclosing CO/CR discrepancies, occlusal interferences, and centric “slides” prior to or during treatment. Mandibular position is evaluated at each appointment, and adjustments to mechanics or possibly buccal segment coronoplasty is done to address interferences that develop in the course of treatment. With disarticulation buttons, it is easy to manipulate the mandible. In those cases where manipulation is difficult and CR cannot be reproducibly determined, a

Figure 10

Pitts Case Management Incisor Display at Rest

Incisor Display on Smile

Transverse Smile Dimension

Resting Lip Support

Crowding

Smile Arc

Buccal Corridors

Gingival Display on Smile

Figure 11

Initial Smile Close Up

Progress Smile Close Up 20 Months, 11 Appointments

“leaf gauge” is used to manipulate, or mounting of models whenever necessary. I have found diagnostic mountings to be most appropriately applied in selective adults, surgery cases where a maxillary procedure is indicated, or cases where the nature of posterior interferences is uncertain.

13. “Micro-Esthetic Detailing”: as a tool in providing dental esthetics: David Sarver has championed the role of micro-esthetics in attaining a wonderful orthodontic result in both hard and soft tissues17, and I agree completely with his approach. The refinement of “white and pink” esthetic contributions is now a routine part of esthetically superior treatments18. We encourage a disciplined approach to both hard and soft tissue refinement during treatment. This includes;

14. “Tooth size refinement”: as a tool in perfecting guidance systems: No matter how well the brackets have been positioned, or how well the case has been managed, attaining centric stops and guidance patterns requires occlusal adjustments.

Summary of the Role of Case Management the “Active Early” Approach: The art of Orthodontics is constantly evolving with the goal of becoming more efficient, and providing better aesthetic and functional results for our patients. Today with the combination contemporary diagnostic approaches, “Active Early” principles of case management, and purposefully designed and built precision appliances from OC Orthodontics; we are excited about the possibilities for the future. The future is so bright I have to wear shades! Until next time……….

orthoevolve.com // © ORTHOEVOLVE 2015

Pitts Case Management

Author’s Comments

Dr. Tom Pitts

Dr. Duncan Brown

“Our goal in teaching continues to be to improve esthetic and functional outcomes, while simplifying treatment mechanics and improving predictability, and efficiency. Combining the “14 Keys of Pitts Case Management”, an “Active early” approach to treatment, and superior OC H4 self-ligating brackets with Pitt’s Broad Arch Forms has gone a long ways to achieving those ends.”

Ackerman J, Ackerman MB, Brensinger CM, Landis JR. A morphometric analysis of the posed smile: Clin Orthod Res 1998;1:2-11. Sarver D. The importance of incisor positioning in the aesthetic smile: the Smile Arc, Am J Orthod Dentofacial Orthop 2001;120:98-111 3 Jimenez-Carlo et al - Are the Orthodontic Basis Wrong - Revisiting Two of the Keys of Normal Occlusion - ISBN: 978-953- 51-0143-7 4 Pitts, T. Begin with the end in mind and finish with beauty: SIDO Published online: 29/05/2014, 39-46 5 Pitts,T - Active Early Principles, OrthoEvolve White Paper, 2014 6 Pitts, T. - Begin with the end in mind and finish with beauty: SIDO Published online: 29/05/2014, 39-46 7 Pitts, T. - Begin with the end in mind: Protocols for smile arc Protection, Clinical Impressions Vol 17; 1: 2009 8 Pitts, T - The Secret of Excellent Finishing, News and Trends in Orthodontics: April 1, Vol 14, 2009 9 Pitts, T - OrthoClassic, a leading authority in orthodontics, OrthoTown November 2014 10 Jimenez-Carlo et al - Are the Orthodontic Basis Wrong - Revisiting Two of the Keys of Normal Occlusion - ISBN 978-953 - 51-0143-7 11 Flemming et al - Comparison of maxillary arch dimensional changes with passive, active, and conventional brackets in the permanent dentition, Am J Orthodontia Dentofacial Ortho 2013; 144: 185-193 12 White, L - Limiting the Sequellae of Poor Compliance - Orthotown November 2014 13 Martin - Goal Oriented Treatment, SIDO 2013: 4-11 14 Flemming et al - Comparison of maxillary arch dimensional changes with passive, active, and conventional brackets in the permanent dentition, Am J Orthod Dentofacial Ortho 2013; 144:185-193 15 Peter E Dawson - From TMJ to Smile Design, Mosby 2006 16 Sarver, D - Enameloplasty and Esthetic Finishing in Orthodontics- Identification and Treatment of Microesthetis features in Orthodontics, JERD Vol 23 No 5, 298-302, 2011 17 Sarver D - Principles of cosmetic dentistry in orthodontics: Part 3. Laser treatments for eruptions and soft tissue problems, AJODO 2005; 127:262-264 18 Brandao, R - Finishing procedures in Orthodontics: dental dimensions and proportions, Dental Press J Orthodontics 2013 Sept-Oct; 18)5): 147-74 1

orthoevolve.com // © ORTHOEVOLVE 2015

PRINCIPLES

“Perfection of means and confusion of goals seems to characterize our age” - Albert Einstein

Introduction: I have been extremely fortunate to have traveled broadly in teaching orthodontics throughout my career. One of the aspects that seems to create a great deal of confusion among orthodontists around the world is the relationship between the means of using a “straight wire” appliance to align teeth and the contemporary clinical goals of excellence in both esthetics and occlusion. Every orthodontist is familiar with the brilliant article by Andrews1, which introduced the basis of “straight wire” theory, which has dominated our profession for the last 40 years. Building tip, torque, and in/out into the bracket as a means of avoiding adverse “wagon wheel” effects of wire bending is the premise of every modern orthodontic appliance, and to this day, I use pre-adjusted appliances for this reason. As with all great ideas, “Straight Wire” theory has some recognized limitations. Thomas Creekmore and Randy Kunik provided a good summary of these: inaccurate bracket placement, variation in tooth structure and tooth facial morphology, variations in the maxilla/mandible skeletal relationships, tissue rebound, mechanically deficiencies in the appliances2, and variable threshold of biological activation, to name a few. The combination of all these factors reduces the ability of the clinician to rely strictly on the appliance to guarantee an excellent occlusal result, with an even less likelihood of reaching superior esthetic goals.

• The first of these is revolves around the core straight wire principle that the wire plane parallel to the occlusal plane is a requisite for excellent occlusions. It is not, and failure to adjust bracket position to meet esthetic need can result in esthetic decline3 in many patients. The contemporary Orthodontist needs expand his/her diagnostic and mechanical understandings beyond reliance on improved “straight wire” appliances to attain superior esthetic results. David Sarver has led the charge on the impact on esthetics of orthodontic treatment mechanics4 where the vertical position of the upper incisor is the prime diagnostic criteria in developing superior esthetics in orthodontics, and I agree with this concept. • The second involves the misconception that incremental increases in arch wires size is an effective means of controlling axial inclination. It is not, and failure to appreciate how to control axial inclination results in frustration in many orthodontists when reliance on “the treatment built into the appliance” fails to deliver. • The third limitation involves the lack of appreciation of the pivotal role of case management in attaining superior aesthetic and occlusal results. The best orthodontic results are attained by the best case managers, regardless of the appliances they use. Today I would like to explore briefly the elements that are within the control of the Orthodontist; bracket position, appropriate use of pre-adjusted appliances, and arch form as they relate to esthetic outcomes.

Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles

Figure 1: Beautiful Smile Arc - The vertical position of the upper anterior teeth relative to the upper posterior teeth determines the Smile Arc. Importantly the Smile Arc extends from first molar to first molar.

Figure 2: SAP bracket placement - to protect the Smile Arc, and improve enamel display, brackets may be positioned in a more gingival position on the upper anteriors than the upper posteriors. This approach may require a wire plane that is gingival to FA, and not parallel to the upper occlusal plane.

Bracket Position as it effects Contemporary Esthetic Goals:

Figure 3: SAP versus Traditional bracket placement: in situations with flat upper occlusal planes, or where more enamel display is required placing brackets with the wire plane parallel to the occlusal planes adversely impacts esthetics.

This approach to bracket placement has come to be called the “SAP”10 Smile Arc Protection approach. The specifics of this approach have been published several times5 11 12, so rather than review those details again, I will cover the positive impact esthetics that SAP10 produces.

For many years, I have been teaching the “Top 10 Esthetic Factors” that can be impacted by orthodontic mechanics. These were recently published in a SIDO article, so this article will deal more specifically with bracket position, bracket selection, and arch form as it relates to these four factors;

• ”Positive and negative” coronoplasty is very important. Patients today want beautiful faces, beautiful smiles, and beautiful teeth. Teeth need to be “optimized” for shape and contour. When done prior to bonding, esthetic recontouring improves the ability to place brackets in the appropriate location to maximize the smile arc, optimize axial inclination, and control 1st and 2nd order changes in tipping mechanics. Prior to bonding, we encourage softening the cusp tips of the cuspids and first bicuspids, normalizing facial irregularities, and optimize length/width ratios of the upper anterior teeth. Other microesthetic aspects of contact point length, appropriate embrasure spaces, and slenderizing for tooth size discrepancies are accomplished after the anteriors are aligned. Centric stop adjustments are made during the finishing stages of treatment. All surfaces that have been adjusted are smoothed with a white stone, and black rubber tips in a high speed hand piece.

• Idealized inclination of the upper incisors and canines: Patients are more sensitive to adverse changes in axial inclination than to changes in A/P position6 • Idealized smile arc: Idealized smile arcs are more attractive especially in women7 • Incisal and Gingival display: Some gingival display, and full enamel display is appropriate in a “posed” smile8 • Wide arch width, particularly in the molars: Smiles with small buccal corridors are more aesthetic, in both men and women9. Placing anterior brackets in a more gingival position improves enamel and gingival display by adjusting the vertical position of the upper incisors and cuspid relative to the upper posteriors. (Figure 1, 2, 3). Lower posterior brackets are placed in a more gingival position to avoid the occlusion, and the lower anterior bracket more incisally to intrude the lower anteriors and optimize overbite (Figure 4,5).

SAP Bracket Positioning: • “SAP Bracket Position10” as a tool in gaining optimal esthetics. Straight wire theory is based on occlusal results but great occlusal results do not always provide great esthetic results. Bracket position must be individualized to patient esthetic need. In patients with “flat” occlusal planes or those requiring increased enamel display, the progression of the wire plane created by bracket position must increase to develop the smile arch by extrusion of the upper incisors relative to the upper bicuspids. In patients with normal occlusal planes a more modest progression in the wire plane is advisable to protect the smile

Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles

Bracket Torque as it effects Contemporary Esthetic Goals:

arc as the upper arch broadens with treatment. Orthodontists tend to focus on intrusion of the upper anterior teeth in deep bite cases with steep occlusal planes, and excessive enamel display which can lead to esthetic decline. A modest progression in still advised in deep bite cases to avoid excessive reduction in smile arc with reduction in overbite. It is important to remember that large bracket progressions in the upper arch must be compensated for by increased “overlevelling” of the lower arch to maintain optimal overbite through bracket position.

• Realistic Expectations and Straight Wire Theory: In straight wire theory, control of first, second, and third order tooth movement is described as being achieved by incremental increases in arch wire size and placement of the bracket slot at FA. It is required to gain optimal torque expression relative to the occlusal plane using arch wires that “fill up the slot”18. The recognition of the limitations of “straight wire theory” has become relatively common, with the conclusion that, ”we need to raise the need for a re-evaluation of the theories of the straight-wire appliance in orthodontics.”19 Few orthodontists fill the slot, so that the prescription “built into” the bracket is seldom expressed. Actual torque expression then is the result of many factors: bracket design, wire/slot play (engagement angle) mode of ligation, bracket deformation on loading, wire stiffness, magnitude of wire torsion, corner radius, initial tooth position, bracket position, and tooth anatomy20. The combination of these effects makes creating torsion within the appliance difficult when relying on incremental increases in wire size, without bending wire (Figure 7) using traditional bracket positions. This is especially problematic in nonextraction, crowded cases where incisor flaring created during the tipping phases of treatment is very difficult to recover later.

Figure 6: Impact of Head Position on Smile Arc - as the smile arc changes with head position, I use NHP (Natural Head Position) as the reference plane for aesthetic based treatment.

• Head Position versus Frankfort Horizontal Plane in Esthetics. The need to standardize the techniques used by orthodontists and anthropologists, to undertake diagnosis and comparative studies of head anatomy generally revolves around the Frankfort Horizontal reference plane. This plane was selected in the outcome of deliberations at 2 craniometric conferences on disarticulated skulls, held in Munich in 1877 and subsequently in Berlin in 1880, and submitted for consideration to the 13th General Congress of the German Anthropological Society held in Frankfort (or Frankfurt) in 1882. A more appropriate plane is clearly visible on a number of Leonardo da Vinci’s proportional drawings13 as a “true horizontal reference line” with the study postured in a Natural Head Position (NHP) which has become a popular reference plane for esthetically driven treatment14. As NHP has been shown to be reasonably reproducible, both in the short and long term15 16 17, and smile arcs are highly dependent on the occlusal plane of the upper arch (Figure 6), I prefer using the natural head position for assessment. Patients should be assessed while standing comfortably, engaged in natural conversation, and generating unposed smiles. The Orthodontist can then make a patient specific decision regarding the bracket progression needed to generate optimal enamel display: larger progressions where more display is required, moderate progressions to protect the existing smile arc.

“Today’s Orthodontist practices at the intersection of art and technology. The challenge of applying appropriate levels of technology to an artistic end result is the art of case management. The best case managers have a sound understanding of the technology they apply on a daily basis”. Fortunately in the “SAP10” - Smile Arc Protection approach, with bracket placement guided by esthetic requirements, benefits arise in the area of third order control. • SAP10 bracket positions are more effective in management of axial inclination early in treatment. This is true during the tipping phases of treatment. Early in treatment, incisor extrusion creates a retroclining movement that helps control proclination as crowding unravels, when supported by ELSE (early light short elastics) and proper disarticulation buttons. Case Management is the key early in treatment, with needed torsion created by wire plane and disarticulation and supported by early elastics.

Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles

Figure 7: Incremental increases in arch wire fail to provide lingual crown torsion when the slot is not filled.

Figure 8: SAP bracket positions decrease the angle of engagement, thereby improving control of axial inclination in dimensional wires.

Figure 9: Even with extreme SAP positions, it is unlikely to develop excessive torsion within the slot, with common arch wire progressions.

Figure 10: “Flipping” the brackets, reduces the angle of engagement further, allowing torsional couple to be developed in light dimensional wires.

Figure 11: Increased AW sizes in “flipped” brackets produce torsional couples within the slot to effectively upright teeth.

Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles

• Other key case management principles: ELSE, disarticulation, and AW progression are more effective. When using SAP9 bracket positions, improvements in esthetic and functional occlusions occur in the first few appointments. Patients notice these changes, and we encourage the use of “every patient/every appointment photography” as a means of validating the mechanical setup and the progress of treatment.

With North American patients seeking broader smiles and fuller lips, treatment has trended towards avoiding bicuspid extractions to achieve that goal, frequently with the adverse side effect of proclined upper anteriors, which is difficult to recover, and not desirable esthetically.

• SAP10 bracket positions are more effective in management of axial inclination during the torsional phase of treatment. This attribute is a key contributor to a case management philosophy that allows changes in both transverse and axial inclination far earlier in the treatment cycle that traditional straight wire treatment would allow. There are other aspects to this “active early” approach which will be appearing in the next few months for those who are interested, but briefly:

Inverting brackets (“flipped”) as a means of creating more lingual crown torsion has been a common case management practice for years, usually as applied to controlling single teeth. Earl Johnson21 provided a very nice summary of using this approach as it is applied to controlling axial inclination of upper lateral incisors. Some companies advocate using “low torque” prescriptions as a means of uprighting proclined teeth, but the reality is that the torque selections involved are frequently not sufficiently negative to accomplish that task. Research indicates that torsion of 20 to 25° between the bracket slot and arch wires (19X25) are required to create the requisite forces22, and this is very close to that attained with “flipped” brackets placed at SAP positions, utilizing commonly used wire sequences (Figure 11).

Bracket inversion as a means controlling axial inclination:

• SAP10 bracket placements reduces the angle of engagement by reducing the torque designed into the Rx, which is advantageous in cases with proclined teeth, crowded upper anteriors, or to recover proclination occurring as a result of relief of crowding (Figure 8). By applying active torsion within the appliance sooner, with lighter forces, treatment has the potential to be both more efficient and more comfortable for the patient.

One of the strategies used in an “active early” approach is to invert (“flip”) groups of upper anterior brackets as a means of creating lingual crown torsion earlier in the treatment cycle. This technique dramatically reduces “slop” within the bracket wire interface by lowering the angle of engagement at the outset (Figure 10) and applies active lingual crown torsion with incremental increases in arch wire size (Figure 11). One of the critical aspects of this approach is that in the inverted or “flipped” Rx, more lingual crown torsion must be applied to the central than the lateral incisor, due to root size, allowing uprighting of the teeth with minimal adjustment to the wire in finishing. Again the H4 Rx provides appropriate torque when “flipped” (-12/-8) for uprighting proclined teeth, compensating for proclination created during unravelling of crowding, or counteracting the effects of class III mechanics. (Figures 12 to 18)

The “10 tooth smile” is touted as representing an esthetic ideal. There are however many excellent students of dental esthetics that prefer a “12 tooth smile” esthetically, and I agree with them. • Secure Force Application: Even with very large SAP10 progressions, application of excessive torsion through incremental increases in wire size is unlikely using commonly employed AW sequences (Figure 9). I have been an advocate of the PSL bracket system for the last 15 years of my career. I utilize OC Orthodontics’s H4 bracket exclusively, and have been very pleased with the performance of the appliance. The familiar Rx (12/8/7) in the upper anteriors, solid gate, .026 depth slot, combined with utilization of “Pitts Standard” and Pitts Broad” arch forms has increased efficiency tremendously.

It has been suggested that when applying “single tooth” activation by “flipping” individual brackets requires that the bracket be uprighted or the wire adjusted once an ideal inclination is achieved18, which is one of the reasons that I suggest “flipping” brackets in groups to activate the appliance. In crowded cases it is desirable to “flip” the upper cuspid bracket to avoid “paddling” of the cuspid with arch development, relief of anterior crowding, or to compensate for the adverse effects of localized torsion in the appliance. In this approach, with the four incisors and cuspids “flipped”, all the anteriors have negative torque (“flocked”), allowing uprighting of the anterior segment with an unbent wire.

Choosing the right torque bracket or groups of brackets can minimize arch wire adjustments in finishing, but the development of “variable torque” appliances has complicated this relatively simple concept. Rather than picking a bracket torque from a constellation of variable torque Rx’s on a tooth by tooth basis, torque selection has been simplified in the “active early” approach to reduce the arch wire adjustments in finishing.

Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles

Figure 12: Sample Case: Extra Oral Photographs.

Figure 13: Sample Case: Intra Oral Photographs

One of the reasons I have adopted the OC Orthodontics’s H4 bracket system is that combination of upright and inverted H4 brackets provides a good variety of torques to choose from, that are applicable in most situations (Figure 12), with a minimal inventory cost to the practice.

Figure 12: Impact of Inverted Brackets - wide selection of torque values achievable with “flipping” brackets in the H4 appliance. This can be utilized in most cases to minimize wire bending while simplifying inventory considerations.

Arch Form as it effects Contemporary Esthetic Goals:

to be inadequate in terms of width in the posterior sections, where transverse arch development provides significant advantages from an esthetic perspective. Wider arches posteriorly also provides the opportunity to gain space and relieve crowding, which is very useful in non-extraction cases.

The “10 tooth smile” is touted as representing an esthetic ideal. There are however many excellent students of dental esthetics that prefer a “12 tooth smile” esthetically23, and I agree with them. Arch form is directly related to the shape of the wire used, not to the bracket system an orthodontist decides to use24. With this in mind, I do not use “standard arch blanks” but shape bendable arch wire to optimize posterior arch development for esthetics. Careful assessment at each appointment, with palpation of the buccal and lingual alveolar processes is required to ensure that the patient’s “biological availability”5 is not compromised.

Fortunately two companies now produce arch forms that mimic this shape; OC Orthodontics’s Pitts Standard and Pitts Broad arch forms, and G&H Wires DYB V3 arch forms both function well. Because research has shown that as much posterior arch development occurs in round wires as occurs in dimensional arch wires21, both these suites have round, square, and rectangular wires in the same arch form. This feature facilitates an “active early” approach to transverse arch development with a greater degree of torsion control whether using familiar wire progressions or square wire progressions when using OC Orthodontics’s H4 appliance.

I have always been challenged by arch forms that are too flat anteriorly, too broad through the cuspid and first bicuspid, and too narrow through the second bicuspid and molars. I have found all commonly used arch forms © 2015 OrthoEvolve, All Rights Reserved

Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles

Figure 17: Improvement in axial inclination during the tipping phase of treatment due to case management. Figure 18: Inverted brackets on the upper anteriors engage a couple early in treatment in light thermally activated dimensional wires. Notice the absence of a couple in the lower arch!

Figure 14: SAP bracket placement, inverted upper anteriors, posterior bite turbos, ELSE (short class III through the bite elastics. Notice the bracket progression increases as through out the buccal segments and anteriors.

Where unadjusted nickel-titanium or beta-titanium arches do not have optimized axial inclination, the practitioner can use shapeable beta-titanium arch wires or stiffer stainless steel to efficiently correct remaining aberrant torque situations.

Figure 15: SAP bracket placement: bracket slot are positioned apical to FA to develop the smile arc.

Summary and the Role of Case Management: I have always been a teacher. During my career I have concentrated on the development of improved simplified “case management” practices, combined with a sound understanding of the impact of varying bracket position, bracket torque and use of modern arch wires forms to assist the orthodontist in creating an artistic end result. Applying these principles will make case management more efficient, and improve the quality of your end results. Today, I choose to activate the appliance as early as possible, using the SAP10 bracket position to adjust vertical position of the incisors, inverting groups of brackets to activate the appliance, selecting arch wire progressions that control axial inclination early in treatment, and using arch forms that develop the posterior segments of the arches sooner. We will be sharing more on the “active early” approach in the coming months, so stay tuned! Figure 16: Improvement in smile arc, gingival display during the tipping phase of treatment

Until next time…….. 17

Dr. Tom Pitts & Dr. Duncan Brown | Active Early Principles

Author’s Comments

Dr. Tom Pitts

Dr. Duncan Brown

1. Andrews - The six keys to normal occlusion, American Journal of Orthodontic, 1972;62: 269-309 2. Creekmore TD, Kunik RL. Straight wire: the next generation. Am J Orthod Dentofacial Orthop. 1993 Jul;104(1):8-20. 3. Ackerman J, Ackerman MB, Brensinger CM, Landis JR. A morphometric analysis of the posed smile: Clin Orthod Res 1998;1:2-11. 4. Sarver D. The importance of incisor positioning in the aesthetic smile: the Smile Arc, Am J Orthod Dentofacial Orthop 2001;120:98-111 5. Pitts, T. Begin with the end in mind and finish with beauty: SIDO Published online: 29/05/2014, 39-46 6. Cao et al - Effect of incisor labiolingual inclination and anteroposterior position on smiling profile aesthetics, Angle Orthod 20;81; 121-129 7. Ker et al - Esthetics and smile characteristics from the layperson’s perspective, JADA, Vol 139; 1319-1327 8. Sarver - The importance of incisor positioning in the aesthetic smile: the smile arc, Am J Orthod Dentofacial Orthop 2001; 120:96-111 9. Martin AJ, Buschang PH, Boley JC, Taylor RW, McKinney TW. The impact of buccal corridors on smile attractiveness, Eur J Orthod 2007;29:530–537. 10. Term courtesy Duncan Brown 11. Pitts TR. Begin with the end in mind: bracket placement and early elastics protocols for smile arc protection, Clin Impressions 2009;17:1. 12. Pitts T. The secrets of excellent finishing, News Trends Orthod 2009;14. 13. Naini - The Frankfort Plane and Head positioning in Facial Aesthetic Analysis - The perpetuation of a myth, JAMA Facial Plastic Surgery 2013;15(5):333-334 14. Ramirez at al, Discrepancies in cephalometric measurements in relation to natural head position, Revists Mexicana de Ortodoncis, Vol 1 No. 1, October- December 2013 15. Nouri st al - Three year Reproducibility of Natural Head Position: a longitudinal study, Journal of Dentistry Tehran University 2006 Vol 3, No 4 16. Pereira et al - Reproducibility of natural head position in children, Dental Press J Ortho, Vol 15 No 1, 2010 17. Peng et al - Fifteen year reproducibility of natural head posture, Am J Orthod Dentofacial Ortho, 1999, 116 (1): 82-55 18. Andrews - The six keys to normal occlusion, American Journal of Orthodontic, 1972;62: 269-309 19. Jimenez-Carlo et al - Are the Orthodontic Basis Wrong - Revisiting Two of the Keys of Normal Occlusion - ISBN: 978-953- 51-0143-7 20. Archambault et al - A comparison of torque expression…in metalic self-ligating brackets, Angle Orthod. 2010;80:884–889. 21. Earl Johnson -Selection of Torque in Straight Wire Appliances, Am J Orthod Dentofacial Orthop 2013;143:S161-7 22. Brauchi et al - Active and passive self ligation: a myth?, Angle Orthod. 2012;82:663–669 23. Martin - Goal Oriented Treatment, SIDO 2013: 4-11 24. Flemming et al - Comparison of maxillary arch dimensional changes with passive, active, and conventional brackets in the permanent dentition, Am J Orthod Dentofacial Ortho 2013; 144:185-193

THE

FACIAL ESTHETICS STUDY GROUP Exclusive group led by Dr. Tom Pitts which includes educational webinars

At OC, we work with orthodontists that want to be the best. We understand that orthodontic ﬁnishing matters most and your work has made you both a craftsman and an artist. You deserve the best tools and you’ve wisely chosen the Pitts 21 or H4 brackets with 3x tighter tolerances than the industry standard. Now it’s time to take your use of the Pitts21/H4 bracket to the next level. We invite you to join our exclusive Pitts 21 Facial Esthetics study group led by the best esthetic orthodontist in the industry – Dr. Tom Pitts. In the ‘Pitts 21 Study Group’ Dr. Pitts will present cutting edge ideas and methods which will improve outcomes while reducing treatment time.

Access to Dr. Tom Pitts and Dr. Duncan Brown to ask questions and seek feedback on Pitts 21/H4 cases Special pricing and ﬁrst access to new OC products Network with some of the best orthodontists in the industry One annual destination meeting includes 16 CE credits First opportunity to register for the exclusive Pitts' Master's Group

Membership Membership requires purchase of 50 cases of H4 along with an annual membership fee of $950. Submit your application today. Membership is limited to the ﬁrst 95 members that apply to facilitate an active and engaging network We look forward to receiving your application!

Phone: 866.752.0065 Online: www.oc-orthodontics.com/PittsSG 19

Rev. C 06/19/17

CONCEPTS

FLIPPING AND FLOCKING “We cannot solve our problems with the same thought processes we used when we created them” -Albert Einstein © O RTH O E VO LVE 201 5

Introduction We live in a challenging time. Orthodontic clinical procedures and esthetic preferences continue to evolve, so that the clinical approaches that we rely on today are different than those that earlier generations of Orthodontists used frequently1. Esthetic declines that were quite common with treatment2 (including flat incisal plane and excesive retraction of incisors) are no longer acceptable to the majority of patients. Where “straight teeth” were once a primary goal, today’s parents/patients frequently seek orthodontic treatment for esthetic improvement3, in addition to health benefits. Contemporary research supports the human social benefits that accrue with improved esthetics such as: more friendly, more intelligent, more interesting, more likely gain better employment, more self confidence, more socially competent4. Fortunately, diagnostic appreciations have kept pace with these trends, with the increasing appreciation of predominance of the upper incisor position in 3 planes of space to esthetic outcomes5, while planning for age related esthetic changes. I subscribe fully to this approach. Virtually every Orthodontist that practices today uses some variant of the “straight wire appliance”, a concept that has dominated our profession since Larry Andrews’ breakthrough article led to its development in the 1970’s. Today I use the H4 bracket, a precision “straight wire” appliance that incorporates a number of unique features at a great price point. Over the years, I have developed a case management strategy that is called “Active Early”, which leverages the features of the H4 appliance (Figure 1), while overcoming many of the misconceptions imposed by rigid adherence to “straight wire theory” for anterior torque and anxial inclination. Today I would like to further expound on the dual roles of case management strategy and appliance selection to address some of the limitations in traditional application of straight wire in a PSL setting in controlling anterior inclination.

Active Early Torsion Model Tipping

Torsion

Early Tipping Mechanics Figure 1: Pitts “Active Early” approach to case management uses lighter forces, applied for longer duration, earlier in the treatment cycle to improve control of both axial inclination and transverse arch development

Non-Adjustable Mechanics

Tipping

Inactive

Adjustable Mechanics

Finishing

Torsion

Straight Wire Torsion Model © O RTH O E VO LVE 201 5

www.oc-orthodontics.com // 2015 Issue 3 21

.028 Slot

Challenges of Torque Expression in a “Straight Wire” Context: Orthodontics lost one of our great thinkers this year with the untimely passing of Charles Burstone. Dr. Burstone clarified the distinction between axial inclination (the buccal lingual inclination of the teeth), bracket slot (labio-lingual) angulation (incorrectly termed torque), torsion (the forces resulting from a couple within the system), and torque expression (the result of torsion). Clinicians, being primarily concerned with torque expression, must be mindful of four things:

10 Weeks - .014

10 Weeks - .018

Contemporary fixed orthodontic treatment is usually completed in wire sizes that are less than full dimension7 for the designed bracket slot. The consequence of this incompletely filled bracket lumen is torsional play that decreases engagement of the contact between the arch wire and the bracket8. While decreasing friction, a potential benefit during early leveling, aligning, and sliding mechanics, torsional play reduces control of axial inclination necessary for ideal esthetics. In clinical practice then, incremental increases in arch wires size is NOT an effective means of controlling axial inclination when the slot isn’t filled9.

Torque expression is a complex process dependent upon10: magnitude of torsion, wire stiffness or resilience, bracket design, engagement angle, mode of ligation, wire dimension corner radius, angulation of the bracket slot, deformation of the bracket or wire under torsion, manufacturing tolerances in the bracket and the wire, initial tooth inclination, bracket position, and the measurement technique used to evaluate torsion. Fortunately, to the clinician, it matters solely when/ if torsion is developed within the slot during commonly used arch wire progressions.

Today’s treatment targets for incisor position in 3 planes of space are based on esthetics11,5, so that reliance on “treatment built” into the appliance through anterior slot “torque” angulation to the occlusal plane is not a practical way to ensure esthetically superior results. In the “Active Early” approach, individualized bracket positions based on esthetics9 (SAP) is combined with other initial planning considerations, to gain control of axial inclination earlier in the treatment cycle than has been possible before.

The hardest torquing mechanics today for many orthodontists is lingual crown torque with occlusal plane variable. Because of this variability, we like to relate the anterior inclination to FH and not the occlusal plane, so that the labial surface of the maxillary incisor is perpendicular to corrected FH.

10 Weeks - .014 x .025

Change to H4 with .026 Slot

.014 x .025

Final

2 Weeks - .014 x .025

Rotational control problems resolved and improved control of axial inclination with H4 bracket and 026 depth slot - Courtesy Daniela Storino 2014

2015 Issue 3 // www.oc-orthodontics.com

“Active Early” Case Management Protocols and the H4 Precision Bracket

In “Active Early” protocols the appliance is activated as early as possible, using the SAP12 bracket position to adjust vertical position of the incisors, inverting groups of brackets where necessary. We have developed protocols to address torsion in the appliance, selecting arch wire progressions that control axial inclination early in treatment, arch forms that develop the posterior segments of the arches sooner, ELSE (Early Light Short Elastics) to control forces and moments, and appropriate disarticulation to encourage early “wanted” tooth movements9,, both A/PE vertical. Working with OC Orthodontics® and their precision manufacturing, we have been able, to introduce meaningful innovations that make an impact on the Orthodontists ability to both control and predict how the PSL appliance will respond. Where commonly used PSL brackets have manufacturing inconsistencies that become clinically significant13, OC has manufacturing tolerances that are much tighter for more predictable performance. Secondly, we have reduced the slot depth to .026, which results in two benefits: improving rotational control, and reducing the engagement angle for torsional control early in the treatment cycle, when using familiar wire progressions (Figure 2) when the bracket is upright. My goal in clinical teaching has been to simplify complex concepts in contemporary case management strategies that can provide significant advantages in the treatment of most orthodontic cases. This distinction is very apparent in the “Active Early” approach to appropriate torque selection.

“Active Early” Approach Removes the Need for “Variable Torques” The concept of variable torque is not new. Andrews was the first to suggest “variable torque” Rx’s to customize the appliance Rx to specific clinical situations (generally extractions). The current approach of “high, normal, and low” torques14 is not practical and overly complicated in my view. With the worldwide tendency to treat more cases without extractions, the control of proclination of the upper anterior teeth has become a greater challenge. Correction of pre-existing crowding and proclination, proclination associated with relief of crowding during traditional round wire mechanics, or incisor proclination associated class III (in the upper arch) elastics is particularly problematic. The challenge for many nonextraction cases has been in getting enough lingual crown torsion without having to resort to complex wire bending to attain esthetic results.

Wire Torsion that Reaches the Target Sooner Figure 2: Combining Pitts SAP bracket position and reduced engagement angle of the H4 bracket system (.026 depth slot) enable development of torsion within the slot earlier in the treatment cycle when the bracket is upright using familiar wire progressions. © O RTH O E VO LVE 201 5

www.oc-orthodontics.com // 2015 Issue 3

Present PSL “Low Torque” Brackets with More Lingual Crown Torque on the Lateral than Central Rx’s do not Simplify Management Significantly While variable torques has been touted to improve this situation, popular brand brackets with more lingual crown torque on the lateral than central Rx’s endorsed by some PSL bracket producers increase case management complexity for me15 in many ways: •

Once in treatment, it is difficult to determine if an individual bracket has the potential to create clinically effective torsion because the slides all open in the same direction. This is very confusing, especially when bracket torques decisions are made on a tooth by tooth basis.

•

Low torque brackets with more lingual crown torque on the lateral than central Rx’s are not sufficiently low enough in the maxillary centrals to overcome both mechanical inefficiency inherent in the appliance, and biological resistance to movement associated with uprighting proclined teeth. At the clinical level, it is difficult to know what “torque expression” can be reasonably expected. Wire bending is almost immediate.

•

When thse low torque variable torque brackets are employed, on individual teeth for localized concerns, the bracket must be repositioned, or the wire adjusted in order to finish well16.

•

When upper incisors with “low torque” brackets with more lingual crown torque on the lateral than central need to be activated further for esthetics, it is impossible to do so with a uniformly spun wire due excessive lingual crown angulation placed in the lateral bracket (figure 3), making either bracket replacement or complex wire bending a necessity.

Bracket Prescription

Low Torque

Simply put, for the most part, use of “variable torques” is confusing and very inefficient.

Torque Selection to Simplify Control of Axial Inclination “Flipping and Flocking” Figure 3: Complication imposed by the use of “Low Torque” brackets where the Rx has greater lingual crown torque on the lateral incisor than the central incisor when uprighting teeth with uniformly spun wires.

To avoid these complications, I have inverted standard torque anterior brackets for years to control axial inclination. Inverting the upper anterior brackets has the effect of building negative crown torsion into the appliance while using a flat wire (Figure 5). The H4 appliance Rx is perfect is this regard, predictable when upright, and appropriate when flipped providing greater lingual crown torque to the central when uprighting of the upper anteriors is required. The single H4 Rx, then provides torque combinations suiting the majority of cases (figure 6) with a minimum of wire adjustments. My teaching partner in crime, Duncan Brown, coined the terms “flipping and flocking” as a memorable way of describing inverting groups of brackets to control changes in axial inclination as a result of pre-existing conditions, relief of dental crowding, or responses to mechanics. To our delight, many Orthodontists around the world now are “flipping/flocking” regularly…….I can’t believe that is now in print.

Figure 5 - Effect of “flipping” an anterior bracket is to place an effective degree of lingual crown torsion in the appliance

upright

“Flipping” places lingual crown torsion in the appliance

flipped

2015 Issue 3 // www.oc-orthodontics.com 24

Figure 6: Wide range of torques available in the H4 bracket system attaining simply by inverting (“flipping”) brackets with an appropriate Rx

Torque Normal Low

U1 +12 -12

U2 +8 -8

U3 +7 -7

U4 -11

U5 -11

Torque High Normal Low

L1 +6 -6

L2 +6 -6

+7 -7

-12

-17

Here are some highlights and benefits of using the technique:

Figure 7: “flipped and flocked” upper appliance, “flipped” lower anteriors in a class III AOB patient

•

Choose bracket torques in groups, rather than on individual teeth. This greatly simplifies bracket selection and case management when using adjustable wires, and avoids having to replace brackets later in the treatment cycle, and simplifies wire bending.

•

Choosing to “flip” upper incisor brackets in cases with mild crowding and proclination, “flock” upper cuspid brackets where significant crowding is present in the upper arch, and “flip” lower incisor brackets when class III mechanics are anticipated. It is immediately apparent, which upper anteriors brackets will have active lingual crown torsion, as those brackets with slides opening to the gingival are “active” when “flipped”. The Orthodontist knows immediately if active torsion is present within the slot or not (Figure 7).

•

Standard wire progressions with “flipped/flocked” brackets will produce effective levels of lingual crown torsion with commonly used wire sequences. As you would expect, uprighting of the upper anteriors requires space, gained through arch development, slenderizing, or use of skeletal anchorage (TAD’s). The use of Pitts’ Broad arch forms are particularly helpful, in supporting arch development early in treatment (Figure 8).

•

When using “flipped/flocked” appliances, incremental increases in arch wire size actually produces incremental increases in effective torsion. This is the way “straight wire” appliances were designed to function.

•

The inclusion of .020X.020 Thermal Activate Nickel Titanium and Beta Titanium arch wires in the Pitts’ Broad arch forms allows active and effective lingual crown torsion to be placed very early in the treatment cycle in either the second or third arch wire (Figure 8). I am finding that many cases finish very nicely in .020X.020 wire dimensions, with .025 wire progressions being best suited for cases where large degree of rotational control is required.

•

When using “flipped” anterior brackets, we encourage the patient to be seen every 6-7 weeks when Beta Titanium arch wires are in place, to assess progress and palpate the upper anterior alveolus.

•

Once ideal axial inclination is attained, the appliance can be “deactivated” simply by reducing the AW dimension or adjusting 3rd order wire bending in Beta T arch wires. Of course it’s important to use alloy/wire profiles no larger than Beta Titanium .019x.025 when using “flipped” appliances.

•

We very rarely resort to stainless steel wires in the “Active Early” technique, although it is available for those who wish it.

Using these principles Orthodontists can achieve surprising benefits for our patients with great efficiency (Figures 9 to 21).

www.oc-orthodontics.com // 2015 Issue 3

Summary and Case Management Considerations In an earlier Pitts Protocol, we introduced the “Active Early” Case Management strategy12. By combining the SAP bracket position to adjust vertical position of the incisors, selecting arch wire progressions that control axial inclination early in treatment, using arch forms that develop the posterior segments of the arches sooner, and relying on ELSE and disarticulation to encourage “wanted” tooth movements, great things are possible. The decision to “flip/flock” anterior brackets as a part of the “Active Early” approach, in combination with the precision and dependable Rx of the H4 appliance makes a quantum leap for our non-extraction and class 3 treatments in the areas that Orthodontists have traditionally struggled with other PSL appliances. In the “Active Early” approach, lighter forces, applied earlier, for longer duration are accomplishing many things more efficiently for the Orthodontist, and more gently for the patient than has ever been possible before. Our work in improving the lives of our patients, and the ease with which Orthodontist can deliver esthetically superior results efficiently is just beginning. With OC Orthodontics, we are continuing to refine the appliance, as the “Active Early” protocols continue to evolve. Look for us to introduce more meaningful innovations in the coming months, and thanks for joining us on the journey. It’s going to be a fun ride! Until next time………..

.014 x .025

.019 x .025

.020 x .020

Active Torsion with Wire Progression Figure 8: “flipped” upper appliance demonstrating effective levels of torsion, increases with incremental AW progressions. Note that 020x020 AW provides almost the same degree of torsion as 019x025

Figure 9: Pre-Treatment Extra-Oral Photographs

2015 Issue 3 // www.oc-orthodontics.com

Figure 10: Pre-Treatment Intra-Oral Photographs demonstrating class III, AOB, with proclined upper incisors

Figure 11: “Active Early” Stage I Mechanics: SAP bracket position, “flipped and flocked” upper H4 appliance, posterior disarticulation, ELSE (TTB short class III elastics FT, anterior reverse rainbow PM) © O RTH O E VO LVE 201 5

www.oc-orthodontics.com // 2015 Issue 3

PRACM - 7 Months, 4 Appointments

Very Nice Control Early in Treatment Figure 12: PRACM appointment (7 months, 4 appointments): Smile Arc is developing and excellent control of axial inclination with tipping and early torsion mechanics

Figure 13: PRACM appointment: good control of axial inclination, and improvement in occlusion with very simple mechanics

Flipped and Flocked Appliance

.020 x .020 TA Figure 14: PRACM appointment: “Flipped and Flocked” upper appliance delivers effective lingual crown torsion to prevent increased proclination of the upper incisor with class III mechanics in the upper arch. Flipping the lower anterior brackets prevents retroclination of the lower anteriors with class III mechanics.

Flipped Appliance © O RTH O E VO LVE 201 5

2015 Issue 3 // www.oc-orthodontics.com

Debond - 16 months, 10 Appointments

Figure 15: Debond Records: very nice esthetic changes, improved smile arc, uprighting of upper incisors, improved incisor display

Figure 16: Debond Records: very nice esthetic change ÂŠ O RTH O E VO LVE 201 5

www.oc-orthodontics.com // 2015 Issue 3

Debond - 16 months, 10 Appointments

Figure 17: Debond Records: uprighted upper incisor, lower incisor has not retroclined excessively with light class III mechanics

Figure 17: Debond Records: upper incisor inclination has improved, lower incisor inclination has not deteriorated ÂŠ O RTH O E VO LVE 201 5

2015 Issue 3 // www.oc-orthodontics.com

Debond - 16 months, 10 Appointments

Figure 18: Debond Records: very nice occlusal change with very simple mechanics, great control of axial inclination

Figure 19: Debond Records: very nice arch development with Pitts Broad arch form

Figure 20: Debond Records: very nice control of axial inclination, the CBCT demonstrates the presence buccal plate ÂŠ O RTH O E VO LVE 201 5

www.oc-orthodontics.com // 2015 Issue 3

Author’s Comments

Dr. Tom Pitts

Dr. Duncan Brown

“Our goal in teaching continues to be to improve esthetic and functional outcomes, while simplifying treatment mechanics and improving predictability, and efficiency. In Active Early case management strategies, “flipping and flocking” the anterior brackets provides activation of torsion within the appliance without bending wires. The H4 precision appliance is perfect in this regards.”

Janson, G. Frequency evaluation of different extraction protocols during 35 years: Progress in Orthodontics 2014, 15:51 Ackerman J, Ackerman MB, Brensinger CM, Landis JR. A morphometric analysis of the posed smile: Clin Orthod Res 1998;1:2-11. 3 Samsonyanova, L. A Systematic Review of Individual Motivational Factors in Orthodontic Treatment: Facial Attractiveness as the Main Motivational Factor in Orthodontic Treatment: International Journal of Dentistry , Vol 2014 4 Jung, M. Evaluation of effects of orthodontic treatment on self esteem, AJODO, vol 138, 160-166, 2010 5 Sarver, D. The importance of incisor positioning in the esthetic smile: the smile arc, AJODO 2001: 120; 96 to 111 6 Andrews, L. The six keys of normal occlusion: AJO, 1972; 62: 269-309 7 Badawi, H - Torque Expression in Self Ligating Brackets. a systematic review: Am J Orthod Dentofacial Orthop 2008 May; 133(5): 721-728 8 Meling, T - On mechanical properties of square and rectangualr stainless steel wires tested in torsion: Am J Dentofacial Orthop 1977 March; 111(3); 310-320 9 Pitts, T - Active early Principles - Pitts Protocols Issue 2, 2015; 8 to 14 10 Archambault A - A comparision of torque expression between stainless steel, TMA, and CuNiti in metal self ligating brackets: Angle Orthod 2010 Sept 80(5); 884-889 11 Cao, L - Effect of incisor labial lingual inclination and anterior posterior position on smiling esthetics: Angle Orthod 2011; 81: 121-129 12 Pitts, T. Begin with the end in mind and finish with beauty: SIDO Published online: 29/05/2014, 39-46 13 Thorstenson G - Comparison of resistance to sliding between SL brackets with second order angulation in the dry and saliva states: Am J Orthod Dentofacial Orthop 2002; 121:472-82 14 Lacarbonara, M - Variable Torque Prescription: State of the Art , Open Dentistry Journal; 2015 (9), 60-64 15 Pitts, T - OrthoClassic, a leading authority in orthodontics, OrthoTown November 2014 16 Johnson, E - Selecting custom torque prescriptions for the straight wire appliance, Am J Orthod Dentofacial Orthop 2013;143:161-167 1

2015 Issue 3 // www.oc-orthodontics.com 32

Pitts 21: Esthetics, Function, & Control The Precise, Low Force System

Dr. Tom Pitts D.D.S., M.S.D. Dr. Pitts is a world renowned lecturer and clinician. He is highly recognized for his continued teaching of orthodontic ﬁnishing and clinical excellence. Dr. Pitts teaches at the UNLV orthodontic department and is the founder of the well-respected Pitts Progressive Study Group and Pitts Masters’ in Finishing 2 year continuum.

SEMINAR TOPICS

2018 Updates

• Contemporary Facial and Smile Driven Orthodontics • 12 Esthetic Keys to Youthfulness and Beauty • Smile Arc Protection / SAP Bracket Position • Keys to Proper Arch Development • “Active Early” Concepts Including Torsion • Open-Bite, Cl III, Cl II Non-Surgical Corrections • Retaining Open-Bites, and Cl III’s • Mastering Esthetics with OC PSL • Enhancements to Pitts' Protocols • Special Event Pricing on Pitts 21

Rev. B

Overcoming Challenges in PSL with “Active Early” and H4 Dr. Tom Pitts Dr. Duncan Brown

â&#x20AC;&#x153;Everything should be made as simple as possible but no simplerâ&#x20AC;? - Albert Einstein

Introduction As orthodontic clinical procedures and esthetic preferences continue to evolve, the clinical approaches that we rely on today are quite different than those frequently used by earlier generations of orthodontists1. Frequency of four bicuspid extraction has diminished with greater acceptance of non-extraction and has been gaining in popularity as fuller lips, broader smiles, and greater enamel display becomes esthetically more desirable (Figure 1,2,3). Most of the fixed appliances today have their torque values based on extraction cases and class II correction with maximum anchorage. Virtually every orthodontist that practices today uses some variant of the “straight wire appliance”, a concept that has dominated our profession since Larry Andrews’ breakthrough article2 led to its development in the 1970’s. Mechanical limitations are inherent in the theory in terms of the potential for torque expression4. Inaccurate bracket placement, variation in tooth structure and tooth facial morphology, variations in the maxilla/mandible skeletal relationships, tissue rebound, mechanical deficiencies in the appliances3, and variable threshold of biological activation are all factors that can affect torque expression. Refinements to the straight wire appliance in the last twenty years have largely focused on minor 3rd order adjustments with the goal of attaining greater predictability of desired 3rd order movements during treatment. The pivotal point is that appliance and treatment techniques must combine to provide forces in a wanted direction to create a positive effect on tooth movement4.

Figure 1: Contemporary macro-esthetic standards include full lips, broad smiles, good enamel display - Courtesy Duncan Brown 2014

Figure 2: Contemporary mini-esthetic standards include broad smiles, consonant smile arcs, optimal axial inclination - Courtesy Duncan Brown 2014

Each orthodontist chooses an appliance system believing that it will help to attain good results. Unfortunately, limitations in the manufacturing processes combined with strongly held misconceptions derived from “straight wire theory” make case management more difficult. Too often, good clinical results are attained “in spite of the technology used, not because of it”. Today I would like to briefly examine the role of the appliance, some widely held case management approaches, and suggest a few simple strategies that can make treatment more efficient, more consistent, and improve the quality of the end result. Far too many treatment outcomes today have excessive upper incisor proclination.

Figure 3: Contemporary micro-esthetic standards include “white and pink” tissues optimized for esthetics and functional health - Courtesy Duncan Brown 2014

How Ligation Method Fits into this Context While there has been much debate on the relative merits of ASL (Active Self-Ligating), PSL (Passive Self-Ligating), and Traditional Ligation, these principles that we talk about today apply to all ﬁxed orthodontic appliances regardless of ligation type. The fact is that the “best orthodontic results are produced by the best case managers regardless of the appliances they use”. I have used self-ligating appliances almost exclusively for the last 15 years. I prefer this ligation method for a number of reasons: I also prefer “passive” ligation, but realized long ago that manufacturing accurate manufacturing tolerances are paramount.

•

Initial Bracket Engagement: With self-ligating brackets, consistent ligation is assured. Once the slide is closed, engagement of the wire/bracket interface is as good as it is going to get. This increases efficiency.

•

Improved Hygiene: Elimination of either steel ligature “pigtails” or elastomeric ties is an asset in terms of improving hygienic outcomes5. A disciplined hygiene control program

“The combination of H4 brackets and Pitts Broad AW’s in “Active Early” case management protocols provides “3D control” earlier in treatment than has been possible with any other system!”

-Tom Pitts

will help ensure beautiful results.

•

Faster Wire Changes: It is very easy to engage wires in a PSL mechanism, so that wire changes can be done very quickly and efficiently.

•

Quick Out of the Gate: Orthodontists around the world have found PSL to be very quick out of the gate in terms of unravelling and crowding but difficult down the stretch, where rotations and torsional control are difficult, often taking longer to achieve excellent finishing. We have changed the slot geometry in the H4 appliance in order to address the typical PSL difficulties and reduce treatment time by several months7.

•

Easier Arch Development and Open Bite Closure: We find that arch development and early mechanics in cases with proclination, crowding, or class III are most easily managed with appliances that have minimal resistance to sliding (RTS). We like the H4 PSL for this.

Studies demonstrate that PSL mechanisms display less RTS than either ASL or traditional ligated systems in round wires. This has led to marketing claims made by some companies that the PSL mechanism would translate to: improved treatment outcomes, shorter treatment times, and fewer treatment appointments. None of these companies have the necessary rigorous clinical research to support these potential benefits. I use the H4 bracket, a more precise “straight wire” PSL appliance that incorporates a number of unique features in a high quality appliance, at a great price point. Over the years, I have developed a case management strategy that is being called “Active Early”, which leverages the unique features of the H4 appliance, overcomes many misconceptions imposed by rigid adherence to “straight wire theory”, and addresses the shortcomings common in other PSL brackets. In PSL, engagement of the wire and slot is entirely dependent on the mechanism rather than on elastomeric ties or steel ligature ties, so it is of paramount importance that the manufacturing tolerances are precise to ensure predictable performance of the appliance. Too much “slop” in the bracket slot leads to difficulty in rotations and torque expression in the anterior region. © O RT H O E VO LVE 201 6

Manufacturing Tolerances Matter Early literature on the potential for torsion created in the appliance was based on theoretical mathematical models. When conclusions derived from this process are applied clinically, the results are frequently disappointing and there are a number of reasons for this. As clinicians are primarily concerned with torque expression, the ability of the appliance to generate appropriate forces and moments is of primary importance, even after patient speciﬁc factors are taken into account. Basic scientific research into manufacturing tolerances of both the brackets and wires have discovered several important facts that have direct clinical application:

•

There is No True Straight Wire Appliance, Even When Using Digital Setup: Very rarely can a case be finished with excellence without wire adjustments (Figure 5).

•

Many Orthodontic Slots Are Very Inconsistent: Many have rounded corners, slot walls that are not parallel, rounded internal line angles, variable slot taper, slot dimensions that are oversized up to 27%9. This variation effects generation of torsion developed within the slot as well as rotational control.

•

Orthodontic Brackets Are Not Rigid: Deformation occurs in an elastic (returns to original shape after torsion is removed) or plastic (permanent deformation) manner when torsion is applied. These deformations can and do occur within torsion ranges commonly applied in clinical practice10, effecting torsional expression.

•

Orthodontic Wires Are Variable: Actual cross sectional geometry and varying material properties effect torsional stiffness and therefore torque expression11. The clinical relevance of this research is that even at 25 degrees of twist (a clinically significant twist), insufficient torsion may be created effectively to change the axial inclination of teeth.

•

Corner Radius of Wires Are Remarkably Variable: The angle of engagement is

. 0 2 2 .026”

dependent on the corners of the wires engaging the super and inferior walls of the slot. The edge bevel contribution to engagement angle can range from .2 to 13 degrees depending on the bracket/wire combinations12. The worst performer in this regard is found in certain beta titanium wires, which is generally favored for increasing torsion through wire bending.

Figure 4

H4 Slot Dimension .022" x .0260" +/- .001" Slot Depth

Figure 5: Too proclined incisors with familiar wire progressions and bracket slot positioned as suggested in “Straight Wire” theory, torsion is unlikely to be developed within the slot © ORT H OEVOLVE 2016

Tolerance

Reducing Challenges of Appliance Manufacturing & Common Clinical Practices We favor the H4 appliance from OC Orthodontics for a number of reasons. OC has a MIM manufacturing process with tolerances that are much tighter for more predictable performance, dense metallurgy minimizing deformation, a rigid slide, and reduced slot depth. These factors improve rotational control while reducing the engagement angle for torsional control early in the treatment cycle, when using familiar wire progressions when the bracket is upright (Figure 6). Figure 6: With familiar wire progressions and bracket slot positioned as suggested in “Active Early” approach, torsion within the slot is developed earlier in the treatment cycle. Popular “low” torque brackets are not low enough to do the job.

Today, I want to initiate wanted forces and moments within the appliance as early in treatment as possible. We use SAP18 bracket position to adjust the vertical position of the incisors for smile arc an enamel display, and invert groups of brackets (“flipped and flocked”) as needed to activate torsion in the appliance sooner. We adopt arch wire progressions and profiles that control axial inclination earlier in treatment. We adopt arch forms that develop the posterior segments of the arches sooner, “ELSE” (Early Light Short Elastics) to control forces and moments, and appropriate disarticulation to encourage specific tooth movements. This has become known as an “Active Early” approach to case management.

An “Active Early” Approach One of the distinguishing features of the “Active Early” approach is adapting to “slop” that is present in all straight wires appliance slots. In this approach a good deal of control is available through a number of clinical opportunities when using non-adjustable wires. Most notable among them are:

Figure 7: Positive effects of “White and Pink” tissue optimization prior to bonding. Courtesy Nimet Guiga and Duncan Brown.

•

Optimize “White and Pink” tissue contour prior to bonding: Patients today want beautiful faces, beautiful smiles, and beautiful teeth; meaning teeth and tissues need to be “optimized” for shape and contour. Prior to bonding, hard tissue recontouring improves the ability to place brackets in the appropriate location to maximize the smile arc, optimize axial inclination, and control 1st and 2nd order changes during tipping or early torsion mechanics. All surfaces that have been adjusted are smoothed with a white stone and black rubber tip using a high speed hand piece. Soft tissue revision using diode lasers are very useful in optimizing bracket position for smile arc enhancement (Figure 7).

•

Patient Specific SAP Bracket positioning: We reject the theory that the bracket slot has to be positioned in the middle of the crown. Bracket position is individualized to meet each patient’s esthetic need. Many patients need more enamel display upon

Figure 8: Although the upper incisor inclination to occlusal plane is the same, esthetic presentation is effected by cant of the occlusal plane - adapted from Rungsi Tavarungkul 2012

smiling. I like to enhance or preserve the “smile arc” on all patients. This requires the divergence of the upper wire plane, created by bracket position, and must increase anteriorly to develop the smile arc by extruding the upper incisors relative to the upper bicuspids. A divergence is still advised in deep bite cases to avoid excessive reduction in smile arc with reduction in overbite. It is important to remember that large bracket progressions in the upper arch must be compensated for by over-leveling the lower arch to establish optimum overbite relationships. A number of articles on the SAP technique have been published in recent years and SAP bracket positioning is now being employed regularly around the world19,20 (Figure 8,9,10).

Don’t believe the mythology that SAP hurts the bracket slot torque. Torques changes in SAP positions are actually an advantage in a high percentage of non-extraction cases. Being closer to the center of resistance of the root provides more control. Most of my non-extraction cases required lowered torque, so we “flip” many upper anteriors in cases of crowding, class III, and proclination as needed (Figure 11).

•

Torque Selection: With the worldwide tendency to treat more cases without extractions, the control of proclination of the upper anterior teeth has become a greater challenge. Correction of pre-existing crowding and proclination, associated with relief of crowding during traditional round wire mechanics, or incisor proclination associated

Figure 9: SAP versus Traditional bracket position - failure to adjust the bracket position to meet esthetic needs can result in flattening of the smile arc and esthetic decline

class III (in the upper arch) elastics is particularly problematic. The challenge for many non-extraction cases has been in getting enough lingual crown torsion without having to resort to complex wire bending and torquing springs to attain esthetic results.

•

Inverting or Flipping Brackets For Flared Upper Incisors: Rather than resorting to a constellation of “variable torque” prescriptions, inverting standard torque anterior brackets builds sufficient lingual crown torsion into the appliance using a flat wire (Figure 11). The H4 appliance Rx is much better in this regard, predictable when upright, and appropriate when flipped providing greater lingual crown torque to the central when uprighting of the upper anteriors is required. The single H4 Rx then provides torque combinations suiting the majority of cases with a minimum of wire adjustments. For the clinician primarily concerned with torque expression, it matters solely when/if torsion is developed within the slot during commonly used arch wire progressions, and “flipping” brackets for proclined upper incisors, ensures that torsion is present in the slot from the outset of dimensional wires. We are teaching orthodontists how and when to “flip” brackets (Figure 11).

•

ELSE (Elastics, Light, Short and Early): I have advocated use of light elastics from the first appointment for the past 20 years, especially when using PSL mechanics. Sabrina

Figure 10: Wire plane and upper occlusal plane are not necessarily parallel in patients with good esthetics and sound functional occlusions Courtesy Duncan Brown 2015

Huang, from Taiwan, suggested the ELSE acronym some years ago, and I continue to describe the technique in those terms. The use of ELSE (no more than 2.5 oz.) increases the efficiency of treatment dramatically by maximizing “wanted” tooth movements in all dimensions, and minimizing or mitigating “unwanted” tooth movements early during the tipping or early torsional phases of treatment (Figure 12,13). Patient cooperation is critical, and reinforcing early progress through “every appointment” photography is very useful. ELSE can minimize “round tripping” on non-extraction cases, and facilitates moving disarticulated teeth with very light forces.

•

Appropriate Disarticulation: The use of OG’s (occlusal guides) to adjust the occlusal plane and maximize wanted and minimize unwanted tooth movements is a important “Active Early” contributor. Teeth move readily with lighter forces when disarticulated. It is

Figure 11 - Effect of “flipping” an anterior bracket is to place an effective degree of lingual crown torsion in the appliance

very important that OG’s are positioned strategically to erupt or intrude the appropriate teeth to improve esthetics and function. We’ll be talking about OG’s in a later issue of the Protocol.

•

Arch Width and Arch form: Using Pitts Broad arch forms allows early development of arch width in the areas where the esthetic benefit is the greatest. It has never made sense to me to start with arch wire forms that are narrower than the case needs to finish esthetically. Working with OC Orthodontics, we have created a full suite of arch wires © O RT H O E VO LVE 201 6

•

develop the arches transversely from the outset to an esthetically pleasing arch form (Pitts Standard, Pitts Broad) (Figure 13), where research has shown that a great amounts of transverse development occurs21. It is very important and optimal inclination of the buccal segments is attained for ideal esthetics and occlusal function, and this is assessed at each appointment. Lifelong retention is a part of this strategy.

•

Torquing Power Chains: In order to help early torque control, i2, i3 torquing powerchains are used as a tool of controlling axial inclination early in treatment. Incisal torquing elastomeric chain to minimize unwanted tipping of teeth during the relief of crowding is proving very helpful, especially in cases where the anterior brackets have not been “flipped” (Figure 14). Dr.

Figure 12: Excellent control of tooth position, and esthetic improvement using “Active Early” principles of recontouring, SAP bracket placement, disarticulation and ELSE- Courtesy of Nimet Guiga 2015

Guiga introduced us to this concept, which has helped significantly in torque control early in cases after the 20X20 TA Niti is placed (Figure 14).

•

Square Wire Early: We have developed a wire progression approach that allows the orthodontist to initiate control of axial inclination through torsion developed within the slot much earlier in treatment than was previously possible. Using 020X020 TA Niti wires allows torsion within the slot to be initiated early, frequently by the 2nd or 3rd appointment. “Square Wire” finishing on many cases provides a simple, effective and efficient means of attaining esthetic results. Look for more innovations in the near future to further improve this approach.

Figure 13: Excellent control of tooth position, and esthetic improvement using “Active Early” principles of recontouring, SAP bracket placement, disarticulation and ELSE- Courtesy of Duncan Brown 2014

H4™ Pitts' Broad H4™ Pitts Standard H4™ Universal

Figure 14: i2 torquing powerchain for torsional control early in treatment - Courtesy of Nimet Guiga 2015

Pitts Broad (blue), H4 Standard (green), H4 Universal (red) arch forms - broader arch forms produce broader arches and broader smiles - Courtesy Tom Pitts 2013

Summary and Case Management Considerations We see efficient esthetic treatment by these active early protocols: • • • •

Combining the SAP bracket position to adjust vertical position of the incisors. Selecting arch wire progressions that control axial inclination early in treatment through using Pitts Wide arch forms that develop the posterior segments of the arches sooner Shortening the depth of the bracket slot. Using ELSE and appropriate disarticulation to encourage “wanted” tooth movements.

The H4 appliance makes a quantum leap for treatment. The ability to “flip” anterior brackets as a part of the “Active Early” approach, in combination with the precision and dependable prescription (Figures 15 - 21) solves issues orthodontists have traditionaly struggled with in most PSL appliances. With OC Orthodontics, we are continuing to refine the H4 appliance, as the “Active Early” protocols continue to evolve.

Figure 15: Initial Records - Courtesy Duncan Brown 2015

In the upcoming issues of The Protocol, we will explore other parameters of “Active Early”. Stay tuned, it will be exciting. Until next time…… Figure 16: Excellent control early in treatment using “Active Early” case management protocols; SAP bracket placement, “flipped” slots 2x2.- Courtesy Duncan Brown 2015

18 Months

11 Appointments

Figure 17: Excellent control early in treatment using “Active Early” case management protocols; SAP bracket placement, “flipped and flocked” upper anteriors, “flipped” lower anteriors, ELSE and disarticulation - Courtesy Duncan Brown 2015

Figure 18: Very nice esthetic change efficiently attained- Courtesy Duncan Brown 2015

Figure 19: Optimized upper incisor positionCourtesy Duncan Brown 2015

Figure 20: Uprighted upper incisor with “Active Early” protocols- Courtesy Duncan Brown 2015

Figure 21: Post treatment CBCT confirming presence of buccal plate - Courtesy Duncan Brown 2015 © O RTH O E VO LVE 201 6

Author’s Comments

Dr. Tom Pitts

Dr. Duncan Brown

“Our goal in teaching is to improve esthetic and functional outcomes, while simplifying treatment mechanics and improving predictability, and efficiency. Working alongside OC Orthodontics we will be introducing more innovative technology and approaches to simplify your mechanics, while providing effective solutions to clinical problems that are also efficient.”

1 Janson, G. Frequency evaluation of different extraction protocols during 35 years: Progress in Orthodontics 2014, 15:51 2 Andrews, L. The six keys of normal occlusion: AJO, 1972; 62: 269-309 3 Creekmore, T, Kunik, R, Straight Wire: the next generation, Am J Orthod Dentofacial Orthop. 1993 104(1): 8 to 20 4 Dalstra,M. Actual versus theoretical torsional play in conventional and self ligating bracket systems: Journal of Orthodontics 2015 (0) 1 - 11 5 Pellegrini,P - Plaque Retention by self ligating versus elastomeric orthodontic brackets: Quantitative comparison of oral bacteria and detection with adenosine triphosphate-driven biuminescencse, Am J Orthod Dentaofacial Orthop 2009; 135:426.e1 - 426.e9 6 Folco, A -Gingival Response in Orthodontic Patients; Comparison study between Self Ligating and Conventional Brackets - Acta Odontol. Latinos 2014, Vol 27 (3) 120-124 7 Anand, M - Retrospective investigation of the f=effects and efficiency of self ligating and conventional brackets, Am J Orthod Dentofacial Orthop 2015; 148: 67-75 8 Badawi, H - the Use of Multiaxis Force Transducers for Orthodontic Forces and Moments Identification, University of Alberta Phd Thesis, fall 2009 9Major, T - Orthodontic Bracket Manufacturing Tolerances and Dimensional Differences between Select Self Ligating Brackets, Journal of Dental Biomechanics, 2010, Article ID 781321 10 Melenka,G - Three-dimensional deformation of orthodontic brackets: Journal of Dental Biomechanics 2013 (4): 1758736013492529 11 Meling, T - On the variability of cross section dimensions and torsional properties of rectangular nickel-titanium arch wires; Am J Orthod Dentofacial Orthop 1998; 113: 546-57 12 Sebanc,J - Variability of effective root torque as a function of edge bevel on orthodontic wires; Am H Orthod 184 Jul;86(1); 43-51 13 Badawi, H - Torque Expression in Self Ligating Brackets. a systematic review: Am J Orthod Dentofacial Orthop 2008 May; 133(5): 721-728 14 Meling, T - On mechanical properties of square and rectangular stainless steel wires tested in torsion: Am J Dentofacial Orthop 1977 March; 111(3); 310-320 15 Pitts, T - Active early Principles - Pitts Protocols Issue 2, 2015; 8 to 14 16 Cao, L - Effect of incisor labial lingual inclination and anterior posterior position on smiling esthetics: Angle Orthod 2011; 81: 121-129 17 Fleming, P - Comparison of maxillary arch dimensional change with passive and active self ligation and conventional brackets in the permanent dentition: a multicenter randomized control trial: Am J Orthod Dentofacial Orthop 2013; 144: 185-193 18 Thorstenson G - Comparison of resistance to sliding between SL brackets with second order angulation in the dry and saliva states: Am J Orthod Dentofacial Orthop 2002; 121:472-82 19 Pitts, T - Begin with the end in mind and finish with Beauty, EJCO 2014;2:39-46 20 Guiga, N - Soft Tissue Diagnosis and SAP Bracket Positioning, The Protocol 2015 V3: 22-31 21 Fleming, P - The Timing of significant arch dimesniosnla changes in fixed orthodontic appliances: Date from multicenter randomized controlled trial, Journal of Dentistry 42 (2014); 1-6

Arch Form Evolution

The Esthetic Possibilities of the Pitts Broad Arch Form & Progressive Archwire Sequence Tom Pitts D.D.S., M.S.D. with Duncan Brown B.Sc., D.D.S., D. Ortho

“Logic will get you from A to B, imagination will take you everywhere!” – Einstein

he most frequent questions that we get asked from orthodontists around the world are related to arch form, and archwire progression. This article will explain why we believe the Pitts Broad Arch Form - a relatively new arch form - produces the most esthetic orthodontics on the market today, and why the Pitts Progressive Archwire Sequence is efficient, effective, and simple. I have been evolving an arch form and approach to archwire progression since my residency. This journey has provided a number of insights. When I was studying at the University of Washington from 1968 to 1970 under Drs. Richard Riedel and Alton Moore, I was taught that - in an attempt to enhance stability - arch form and arch width should reflect the original malocclusion prior to treatment. Over 35 years of data collection from the faculty at the Department of Orthodontics at the University of Washington has clearly demonstrated that long term stability is highly unpredictable. “Orthodontic treatment is inherently unstable and without retention relapse is inevitable.”

Because of these findings, my own clinical experience and that of the thousands of orthodontists I’ve coached and spoken with over the course of my career, I believe in lifetime nighttime retention of orthodontic finishes. Shortly after graduation in 1970 I enrolled in the first FACE continuum, studying with Dr. Ron Roth. Dr. Roth had adopted an arch form that was horseshoe-shaped and very wide in the anterior. After using this arch form for some time, it became clear to me that cases treated with arch forms too broad and flat in the anterior and too narrow in the molars do not create esthetically appealing finishes. Later, a group of innovative orthodontists with which I was affiliated (the A Company Innovation Group), developed an arch form sometimes called the “Universal” or “Damon” arch form. This arch form was subsequently adopted by many orthodontists around the world and seemed at first to be able to achieve results more esthetic than previous arch forms. After using the Universal and Damon arch form for many years, however, I found the shape lacking.

70 mm

13 cm

5 mm

Broad vs Universal

1 cm

UPPER/LOWER

H4™ Pitts Broad

3 20

H4 Pitts Standard ™

30 30 CC

40 40

H4™ Universal

50 50

40 mm

7 6 5 4 3 2

60 60 70 70 80

10 A A BB

10 10 A A 20 BB 30 CC 30

4 5

40 40

50 50

60 60

40 mm

70 70

9 10

20º 10º 10º

11 12

20º 1 cm 5 mm

Figure 1: Evolution of esthetic arch forms: “Pitts Broad” arch forms are preferred - courtesy Tom Pitts 2013

13 cm 70 mm

Figure 2: Comparison of Pitts Broad and Universal Arch form developed by Tom Pitts - courtesy Tom Pitts 2013

Figure 3: Esthetic changes associated with change in arch form created through arch shaping in adjustable archwires - courtesy Tom Pitts 2013

Cases were not broad enough posteriorly for great esthetics and required further arch shaping in adjustable wires. Using wires with this arch form in conjunction with traditional archwire progressions through the nickel titanium archwire stage, it would take eight months to a year to progress to an adjustable archwire (TMA or Stainless Steel) where further posterior arch development would need to be initiated through wire shaping. This was effective but not efficient.

Figure 4: Esthetically derived arch forms created through wire bending were the basis of Pitts Broad Arch Form (no molar distalization) - courtesy Tom Pitts 2013 Macro-Esthetic Finish Evaluation

20 Months | 11 Appmts

Figure 5: Esthetic gain of a broader smile, not too wide in the canines, great smile arc, full enamel display on smiling, and optimal incisor inclination - courtesy Duncan Brown 2016 Macro-Esthetic Finish Evaluation INITIAL

20 Months | 11 Appmts FINAL

Figure 6: Arch Width and Arch Form changes associated with esthetic gain - courtesy Duncan Brown 2016

When I attended Dr. Robert Rickett’s continuum in 1975, I began to appreciate the treatment outcomes obtainable from a more esthetic arch shape that offered less expansion in the canine region and greater broadening at the molars. This arch form resulted in very esthetic smiles with less negative space in the buccal corridors. I began to mimic this shape when using adjustable wires and to gradually develop width in the molar region to maximize tooth display in the buccal segments (Figures 1-3). The result mirrors current concepts of dentistry where 12-tooth smiles are considered the most esthetic. Obviously, some “out of the box” thinking is required to develop a system (bracket geometries, arch form, and archwire progression) that is efficient, effective, simple to use (and to train), that allows the orthodontist to consistently produce exceptional esthetic results. Fortunately, OC Orthodontics has a corporate culture that is committed to meaningful innovation.

Arch Form and Today’s Esthetic and Functional Expectations: Today, as I interview and show photographs of excellent smile esthetics to potential patients, they readily appreciate the esthetic value of fuller lips, broader smiles, great smile arcs, full upper teeth display upon smiling and optimal inclination of incisor teeth for esthetic presentation. Inevitably they will all say “I want that”. For their smile to “age well”, anticipation of facial aging changes must be incorporated into treatment designs as a primary focus rather than an afterthought,1 (Figure 4 - 9) Throughout the world, there is an increase in preference for non-extraction mechanics2 to fill esthetic needs. Unfortunately for many, non-extraction biomechanics is frequently accompanied by the challenge of controlling upper anterior proclination associated with the relief of crowding. As we addressed in a previous version of the Protocol, control of axial inclination is achievable through the use of Active Early protocols with flipping the H4 brackets 180º3. For more information about the Active Early protocols, see an overview of it later in this article and also in issue 2 of The Protocol. I have flipped upper anterior brackets for many years along with widening the buccal segments to control anterior axial inclination in non-extraction cases that had the potential to procline. Another challenge of broadening bicuspids and molars with fixed appliances is that axial inclination of the buccal segments must be controlled. Even though we use -27 degree torque brackets on upper molars and -22 on lower molars, we sometimes spin a little lingual crown torsion in the wires as we develop posterior arch width. Research has confirmed that final arch width is a function of archwire form, not of the bracket4 used during treatment. In response to the need for an improved arch form, broad in the molars (filling out buccal corridors), tapered in the anteriors (improving incisor flow and presentation), and slightly narrower than conventional arch forms in the cuspids and first bicuspids (enabling 12-tooth smiles during animation), I

developed the Pitts Broad arch form. In most patients, this arch shape fosters the 12-tooth smile. I have worked with the engineers at OC to develop all the wires I use - both the Pitts Broad and Universal arch forms. Beginning treatment with the Pitts Broad Thermal Activated Nickel-Titanium (TA NiTi) archwires gives the arches a chance to widen very early - part of the Active Early protocols. Esthetic concepts of “Golden Proportion”2 have largely been eclipsed by the concept of “Crown Virtual Widths”5 in dental esthetic circles as a means of describing the visual “flow” desired in esthetically aligned teeth, and we subscribe to this concept. We view transverse development of esthetic arch forms as being independent of tooth size or extraction preference so that a single arch form, adjusted to meet esthetic need and compensated for biological availability is preferred. We reject the concept that patients with reduced tooth mass (either through extractions or smaller mesial distal widths of anterior teeth) should be treated with narrower arch forms6. To me, the arch shape is more important to smile esthetics than the proportions of the anterior teeth sizes to each other. (Figure 10 - 15) Caution should be exercised in widening bicuspids and molars in patients with a thin periodontal biotype. We ascribe to the concept suggested by Dr. Michael Major (Edmonton, Alberta) of continuous assessment of the patient’s biological availability to desired tooth movements as being especially valuable. In patients with thin biotypes, patients with thin labial and lingual thickness of labial/buccal/lingual bone plates at the level of root apex, or patients with pre-existing bony fenestrations7, I modify the arch form to do very little widening, and assess progress through palpating of the labial and lingual plates at each appointment. This is a direct compromise where imposed biological limitations “trumps” esthetic desires. It has been reported that achieving transverse arch development in the cuspids, bicuspids, and molars is highly effective with round thermally activated wires8. OC provides a full suite of archwire sizes and profiles so that arch form can be developed from the onset, producing arch forms that mimic esthetic arch shapes formerly created by wire bending. OC provides the following arch forms (Figure 1): Pitts Broad (which we use almost exclu-

sively), Pitts Standard (which we use rarely) and Universal (for patients with limited biological availability or for wide lower arches and low torque). Subtle adjustments in final archwire shape in response to esthetic needs or biological limitations and minor torque corrections are possible in Beta Titanium and Stainless Steel archwires. When using an Active Early approach - where torsional control and transverse arch development is achieved early

Figure 7: Esthetic changes associated with change in arch form created through arch shaping in adjustable archwires - courtesy Tom Pitts 2013

Figure 8: Esthetically derived arch forms created through wire bending were the basis of Pitts Broad arch form - courtesy Tom Pitts 2013

in treatment - use of stainless steel archwires is seldom required, but these archwires are available for user who like them.

Management of Arch Form and Archwire Progressions: In Active Early protocols,9 the appliance is activated as early as possible using the Smile Arc Protection (SAP)10 Bracket Positioning to adjust vertical position of the incisors, inverting groups of brackets when appropriate to activate torsion in the appliance, selecting arch wire progressions that control axial inclination early in treatment, arch forms that develop the posterior segments of the arches sooner, Early Light Short Elastics (ELSE) to control forces and moments, and appropriate disarticulation to encourage early “wanted” tooth movements as well as extrusion or intrusion. In contrast to conventional “straight wire thinking” where forces for torsional correction or transverse arch development are applied in short duration later in treatment and at higher force levels, the Active Early

Dr. Nimet Guiga

Figure 9: Esthetics delivered by Pitts Broad arch form create “WOW” smiles - courtesy Nimet Guiga 2016 12

Macro-Esthetic Finish Evaluation

20 Months | 13 Appmts

Figure 10: A broad smile, great smile arc, and full enamel display is critical in patients with smaller teeth - courtesy Duncan Brown 2016

Macro-Esthetic Finish Evaluation

20 Months | 13 Appmts

Figure 11: Esthetic gain of optimal incisor inclination -courtesy Duncan Brown 2016

Macro-Esthetic Finish Evaluation INITIAL

20 Months | 13 Appmts FINAL

Figure 12: Arch Width and Arch Form changes associated with esthetics gain - courtesy Duncan Brown 2016

Macro-Esthetic Finish Evaluation

3 Months | 2 Appmts

Figure 13

Figure 14

Figure 15: Esthetic gain using Pitts’ “Active Early” in control of axial inclination early in treatment in a compliant patient- courtesy Duncan Brown 2014

approach applies lighter forces, earlier in treatment, and for longer durations. The Pitts Archwire progresssion leverages the tighter tolerances and reduced buccal-lingual slot dimensions of the OC H4 appliance and this sequence is specifically designed for use with the esthetically optimized Pitts Broad arch form and the Pitts Active Early protocols of case management.

Stage 1 - Arch Development and Torsion in Non-Adjustable Wires In the past, wire progressions recommended for PSL brackets were intended for the use of light forces over long appointment intervals with the goal of initiating transverse arch development, controlling axial inclination using non-adjustable wires in the early stages of treatment. While this approach is still applicable for very crowded cases, the H4 appliance - with its shortened slot depth and more accurate slot tolerances - provides more treatment opportunities. The goal of the Active Early protocols using the Pitts Archwire progressions is to move into .020” x .020” thermally activated archwires as early as possible to enable both transverse development (with Pitts Broad arch form) and anterior axial inclination control (through torsion developed in the slot). Dr. Ricketts held that a square wire is gentle and as effective in achieving torsion as using a rectangular wire and the science supports this claim11. Control of arch development and anterior axial inclination is maintained during the early stages of treatment by using light, short elastics (ELSE) from the first appointment, bite turbos, and other Active Early approaches. We suggest seeing patients every 6 weeks for the first 3 appointments by which time .020” x .020” thermally active archwires are usually in place. Most cases are started with .014” TA NiTi or .018” x .018” TA UltraSoft NiTi (in cases without significant crowding or rotations). Both of these archwires come in the Pitts Broad arch form. For cases started in .014” TA NiTi archwires, patients are seen 6 weeks after bonding, then transitioned to .018” x .018” TA UltraSoft NiTi for 6 weeks. The goal is to get to .020” x .020” TA NiTi in 6 to 12 weeks, which initiates torsion developed within the slot via archwires while continuing arch

form development. Square wires are great for torquing in lieu of rectangular wires. The .018” x .018” UltraSoft NiTi is a new archwire we developed at OC. In patients where difficulty in resolving rotations occurs, we suggest progressing into .018” x .025” TA NiTi after the .020” x .020” TA NiTi. With the .025 dimension in the H4 .026” depth slot, rotational correction should be easily acquired if the brackets are correctly positioned.

Stage 2 - Torsion and Arch Shaping in Adjustable Wires In the adjustable wire phase of treatment there are several alternatives: Without Rotations: In cases with few or minimal rotations, it is usually possible to move to completion in .020” x .020” Beta Titanium archwires. This wire is easy to adjust for individualized esthetic arch form and single-tooth adjustments of axial inclination. Clinicians should expect 2nd order adjustments, but axial inclination should be close. (Figure 16 to 19) With Rotations: In cases where further rotational control is desired, progression into the .025” wire is desirable. As torsion has been occurring within the slot for some time, axial inclination should be well controlled at this point: ■■

We suggest transition from .020” x .020” TA NiTi to .018” x .025” TA NiTi in these patients. In adjustable archwires, .017” x .025” Beta Titanium or .019” x .025” Beta Titanium represents familiar finishing wires for most experienced PSL user. • With flipped upper anterior brackets (either lateral-to-lateral or canine-to-canine), .017” x .025” Beta Titanium hits the “sweet spot” or optimal torsional and rotational forces. We have not found wire dimensions larger than this to be necessary. • In cases where greater torsional correction is desired, .021” x .025” TA NiTi is a good alternative, progressing to .019” x .025” or .017” x.025” Beta Titanium for finishing.

Macro-Esthetic Progress Evaluation

9 Months | 4 Appmts

PITTS BROAD ARCHWIRE PROGRESSION Start with .014 Thermal Activated Nickel Titanium (TA NiTi) or .018 x .018 Ultra Soft Thermal Activated Nickel Titanium

.020 x .020 Beta-Titanium (BT) .020 x .020 TA NiTi .018 x .025 TA NiTi

Figure 16

.021 x .025 TA NiTi

.019 x .025 BT

.017 x .025 BT Figure 20: Simplified arch wire progression strategy using 022x026 H4 appliance — courtesy Tom Pitts 2016

Figure 17

The .018” x .018” Ultra-Soft Thermal Activated NiTi wire is breakthrough technology. We start many cases with this wire, including the second molars in the strap up on the first appointment. Progression to .020” x .020” TA NiTi in 6 weeks is very common. In cases where more rotational control is required, progression to .018” x .025” TA NiTi prior to .017” x .025” Beta Titanium is usually possible. Because of the tighter tolerances of H4, many clinicians using it have been able to save several months of finishing time than with previous PSL brackets using the wire progression strategies just discussed.(Figure 20). We use Thermal Activated NiTi not Super-elastic NiTi - for all these wire progressions. Don’t clinicians want more effective, efficient and simpler treatment mechanics? Working with OC, we will be continuing to introduce innovations to positively impact orthodontics, particularly from an efficiency standpoint. Look for these innovations to be forthcoming!

Figure 18: In Stage 2 the clinician should expect some 2nd order corrections will be required in the .020” x .020” archwire progression - courtesy Duncan Brown 2016

Cases and Stainless Steel Archwires: We have found that stainless steel archwires are rarely needed in non-extraction cases, but are available for those who prefer them. I use them for extra widening when needed and for extraction cases where we typically use .016” x .025” stainless steel archwires for final space closure. To Summarize: Our goals in orthodontics are driven by “wow” esthetics and designed to compensate for - or counteract - the effects of aging. For many orthodontists, such goals constitute a new context for their treatment planning and clinical protocols. The scope of treatment is continually expanding. To remain competitive in an esthetically driven professional environment is a challenge. The Pitts Broad arch form - in combination with the H4 bracket and the associated Active Early protocols - offer new tools that are designed to simplify your lives while improving patient results.

Figure 19: Good torsional control is present with flipped upper anteriors and canines with .020 x .020 Beta Titanium archwire — courtesy Duncan Brown 2016

We welcome you to join us for the Pitts Global Masters Continuum starting March 23, 2017. This is a four session comprehensive continuum over a two year period. For more information visit www.orthoevolve.com or contact Joni Abel at 775.720.7222 or email jonibeedle@yahoo.com. We are planning more innovations so stay tuned! Great to have you along! Until next time...

Drs. Tom Pitts and Duncan Brown 50

Author’s Comments

Dr. Tom Pitts

Dr. Duncan Brown

“Most orthodontists think achieving the esthetic results they want comes down to the bracket they use. The truth is that the wire used is just as important as the bracket when attaining efficient and superior results. Working with OC Orthodontics, we have developed a bracket and wire combination that is effective, efficient, and simple. Outstanding and predictable results, with a reduction in inventory, are now obtainable when using the Pitts Broad Arch Form in combination with the H4 bracket and Active Early Protocols. Try it, you’ll love it!” - Dr. Tom Pitts

REFERENCES 01. Sarver, D. - Growth Maturation and Aging: How the Dental Team Enhances Facial and Dental Esthetics for a Lifetime: Compendium May 2010; Vol 31 No 4, 274-283 02. Janson, G. - Frequency evaluation of different extraction protocols during 35v years: Progress in Orthodontics 2014; 15:51 03. Pitts, T. and Brown, D. - Flipping and Flocking. The Protocol V3 2015: 6 - 18 04. Flemming, P - Comparison of maxillary arch dimensional changes with passive, active, and conventional brackets in the permanent dentition: A multi-center,

randomized clinical trail: Am J Orthod dentofacial Orthop 2013; 144; 185 - 193

05. Brandao, R. - Finishing procedures in Orthodontics and proportions (micro-esthetic). Dental Press J Orthod. 2013 Sept-Oct; 18(5);147-174 06. Waugh, R. - A Specialty Reunited - Finding Common Clinical Ground in Arch Development - OrthoTown April 2010 39-43 07. Garib, D. Alveolar bone morphology under the perspective of computed tomography: defining the biological limits of tooth movement: Dental Press J Orthod

2010 Sept-Oct;15(5): 192-205

08. Flemming, P. - The timing of significant arch dimensional changes with fixed orthodontic appliances: Data from a multi-center randomized control trail. J Dent

2014 Jan; 42(1): 1-6

09. Pitts, T. Brown,D. “Active Early” Principles: Pitts Protocols 2015 (2); 8 - 15 10. Pitts, T. Begin with the end in mind and finish with beauty: SIDO Published online: 29/05/2014, 39-46 11. Archambault, A. The effect of wire alley on torque expression in metallic self lighting orthodontic brackets. Thesis submitted to Faculty or Graduate Studies

and Research, Edmonton, Alberta, 2009

12. “WOW” Smiles created by Dr. Nimet Guiga http://guigaorthodontics.com

I.L.S.E.

Immediate, Light, Short, Elastics with Disarticulation Tom Pitts D.D.S., M.S.D. with Duncan Brown B.Sc., D.D.S., D. Ortho

“Knowledge is a process of piling up facts; Wisdom lies in their simplification” – Martin Fischer

istorically, the use of orthodontic elastics for the treatment of inter-arch tooth discrepancies dates back to the dawn of orthodontics when Calvin Case and Henry Baker used natural rubber products as “inter-maxillary anchorage”1 prior to the 1900’s. Edward Angle first described the technique before the New York institute in 19022, and most orthodontic patients treated since then have used either inter-maxillary or intra-maxillary elastics at some point in their treatment. Despite their obvious significance in orthodontic mechanics, little research and only very basic articles regarding the use of elastics has been done. Today we’d like to give an introduction to our current approach when using elastics (usually with disarticulation) as an adjunct in “Active Early”3 treatment protocols.

Figure 1: Transfer cases 18 months into treatment - Courtesy Tom Pitts 2017

Exact forces required to move teeth are not known The force magnitude for “optimal tooth movement” has been one of the holy grails of orthodontics since Schwartz4 advanced the concept of “the force leading to a change in the tissue pressures that approximated the capillary blood pressure, thus preventing their occlusion in the compressed periodontal ligament”. While there has been a good deal of animal research, human studies have been very limited. Reitan’s study in the 1960’s suggested that the optimal force level for tooth movement was 5 N (approximately 50 gms) of force. Clinically, it has been obvious to me that teeth will move with forces that are much smaller than commonly used if they are precisely applied5. For years orthodontists, have had to resort to heavier forces than we needed. Once we began using passive self-ligation and taking IO photos every visit, I was able to see that we could use very light elastics at the very first appointment to attain desired changes (Figure 1-6). This is far more comfortable for the patient, and we achieve better cooperation, as a rule. With the widespread adoption of PSL approximately 20 years ago, clinical protocols have been developed that reduce the level of applied forces to increase patient comfort while improving clinical efficiency for me. Our ILSE (Immediate Light & Short Elastics)

Figure 2: Transfer cases 18 months into treatment - Courtesy Tom Pitts 2017

Figure 3: Popular “blue grass” roller did not provide resolution of the AOB or tongue thrust Courtesy Tom Pitts 2017

Figure 4: Pitts “Active Early” protocols: SAP bracket position, “Flipped” upper anterior brackets, Pitts Broad AW’s, ISLE (triangle elastics), NMI (squeeze exercises, lower tongue tamers) are applied - Courtesy Tom Pitts 2017

7 WEEKS

Figure 5: ISLE protocols involved wear of “Vertical Triangle” elastics full time, and Pitts P.T. squeeze exercises.

protocols deliver light, precise forces in support of mechanics. ILSE and PSL are great marriage. In contrast to some contemporary protocols where inter-maxillary elastic forces of 4.5 to 6.0 oz. are commonplace, “Active Early” approaches seldom employ elastic forces greater than 4.5 oz. and frequently 2.5 or 3.5 oz. To minimize inventory and simplify elastic selection, our protocols use mainly six elastic types, and most our treatment can be accomplished with only four. We have 2 sizes, 3/16 and 5/16 and 3 forces levels of each of these sizes 2.5, 3.5, 4.5 ounces.

There are a variety of factors that degrade elastic force over time Both Latex and Synthetic (non-latex) elastics and elastomers display a reduction in loss of strength when stretched over a period of time, and exposed to various fluids that may be ingested during in vitro testing. Force degradation during function approximates 25% in the first 24 hours6, with most of effect occurring in the first 3 to 5 hours7. With this in mind, we suggest changing elastics after each meal, which applies a more consistent level of force supporting mechanics.

Elastic compliance is critical to attain a designed result With “active early” esthetic treatment planning protocols, elastic wear is critical to

achieve the desired results. “Every patient/ every appointment” photos supports patient compliance, and fully involves the patient/ parent in the treatment process by revealing progress from the previous appointment.

Routine intra-oral photos every visit “Active Early” case management protocols are very efficient, and it is important to keep this in mind during esthetic orthodontic treatment. This is not a “set it and forget it” approach. Every appointment requires a regular routine of photography, review of patient progress, and adjustment of case management (where it is required). Use of treatment milestones allows this process to be systematic - PRACM (Pano reposition adjust case management). Progress IO photos are most important for adjusting case management and mechanics.

Derivation of ISLE - Immediate, Short, Light, Elastics As with many other clinical advances, ISLE and disarticulation protocols were developed as a combination of luck and experience. In 1977, when I was testing lingual appliances, I found that in deep overbite cases with lingual appliances, the posterior teeth were disarticulated. The posterior teeth came together by eruption and no intrusion of the upper anterior teeth was necessary to reduce the overbite. Leveling naturally occurred, but on some cases it took some months for the posterior

7 WEEKS

Figure 6: Excellent patient co-operation in elastics wear, and Pitts PT exercises contributed to the progress to date in just 7 weeks. Notice the improvement in incisor inclination due to “Active Early” case management Courtesy Tom Pitts 2017

Supported by NMI Mechanism was supported by neuromuscular intervention, tongue tamers, and Pitts PT squeeze exercises.

Figure 7: In many Class II div 2 patients, incisor exposure is near ideal prior to treatment - Courtesy Tom Pitts 2017

teeth to begin occluding. I began using composite bite buttons behind the upper centrals, which became known as bite turbos (derivation of the name turbos is unknown). However, not only did some patients take a long time to erupt the buccal segments, some would return on their first visit biting behind the bite buttons with the lower anteriors. I added some short light elastics to mitigate against this, using the lightest forces possible (2 oz., 3/16”) to close the posterior bite. When patients wore the elastics (full time), starting with the first appointment, from the lower 6 to the upper 4, the posterior teeth were touching in 6 to 8 weeks and biting behind the turbos was no longer a problem. By observing the IO photos, the AP corrected slightly. There were no deleterious effects. Today, we have developed ISLE protocols and combined groups of elastics designed to increase VIP (Vertical Incisor Position; this acronym was suggested by Dr, Dwight Frey) cant the occlusal plane, and broaden arches-improving occlusion and esthetics from the first appointment. This is a major factor in being able to treat more cases nonextraction with “WOW” esthetics.

A Practical Clinical Approach “Active Early” treatment protocols are designed to apply lighter forces for longer durations earlier in the treatment cycle to improve efficiency for the Orthodontist and gentleness for the patient. Each of the parameters of pre-bonding coronoplasty, SAP/VIP bracket placement, use of precise PSL bracket slots, practical torque values, (inverting brackets as needed), combined with appropriate disarticulation, early elastics, and NMI (neuromuscular intervention) improves esthetic and occlusal results quickly with very light force levels.

Figure 8: Protection of existing smile arc and incisor display is critical to esthetics. Eruption of the lower posterior teeth and protection of upper incisor position by SAP bracket position is supported by disarticulation and ISLE Courtesy Tom Pitts 2017 Pitts “Active Early” protocols: SAP bracket position, Pitts Broad AW’s, ISLE (Short Class II), anterior disarticulation are applied - Courtesy Tom Pitts 2017

By clinical trial and error, we’ve found less need to distalize molars of many crowded cases, due to our esthetic positioning of incisors, torque control, and arch development providing needed space. Light inter-arch elastics save a tremendous amount of time and effort in treating all different types over malocclusions, with attendant esthetic enhancement. Yes - we begin most treatments with light elastics at the first appointment.

Disarticulation and Early Elastics The most frequent questions that we are asked when teaching involves the case management techniques with elastics and disarticulation. One of the subtleties of case management of continuous arch wires in fixed mechanics is flaring associated with relief of crowding and is counter to esthetic or occlusal outcomes. We do not need to use reverse curve wires with our technique. With our active early protocols we can generally treat non-extraction cases and end up with proper inclination of the anterior teeth. We advocate approaches that are simple, efficient, effective, and predictable; for that reason we do not use MEAW mechanics (Figures 1-6). That is only needed when using twin-tie brackets.

Disarticulation ILSE and disarticulation work together in “active early” case management. Disarticulation removes the occlusal influences of malocclusion and permits selective eruption and intrusion of teeth and arch development to meet esthetic and occlusal goals. We use either Bandlock (blue) or Pink Triad gel for posterior turbos (pillows) or Triad rope (pink) for anterior turbos. These materials are easily adjusted (reduced or increased), distinguishable from natural teeth (facilitating removal), and wear more easily than enamel (preventing tooth wear).

Figure 9: Great improvement in only 6 weeks. “Every appointment imaging” reinforced the progress with the patient/ parent, and advancement of wires to 018X016 UltraSoft TA NiTi was possible. Today, I would place the bite openers (turbos) on the upper first bicuspids with a bite ramp to let the lower jaw come forward. - Courtesy Tom Pitts 2017

Adjustment of the position or size of bite turbos requires constant management, in response to treatment response for maximum benefit. “Setting and forgetting” disarticulation is a common error. Disarticulation strategies have evolved considerably to improve efficiency and patient comfort. Anterior Bite Turbos: We use disarticulation that is more anterior in deeper bite cases, reducing overbite through selective eruption of the lower posterior teeth, and intrusion of the lower anterior teeth, supported by SAP bracket placement and ILSE. Where good upper incisor display is present, anterior turbos behind the upper anterior

Figure 10: Great improvement in only 6 weeks. “Every appointment imaging” reinforced the progress with the patient/parent, and advancement of wires to 018X018 UltraSoft TA NiTi was possible - Courtesy Tom Pitts 2017

Figure 11: Continued improvement. As most rotations were completely resolved, finishing was possible with 020X020 Beta T with a minimum of AW adjustments, further adjustment of occlusion as the posterior teeth seat into occlusion. 8 months from beginning of treatment. - Courtesy Tom Pitts 2017

Figure 12: Finishing procedures involved continue wear of the light Class II elastic, and Down and Under elastics to complete seating of the occlusion. The anterior disarticulation can be removed once the posterior occlusion is fully seated.

ÂŠ O R THOEVOLVE 2017

teeth, provides rapid reduction of overbite, while preserving enamel display. Several years ago we found that placing turbos on the upper cuspids, was more comfortable for the patient, and still effective early in treatment. Most recently, we have adapted an approach suggested by others, including Dr. Keith Sellers in Charlotte, using bite turbos on the upper first bicuspids incorporating bite ramps to encourage forward mandibular positioning (similar to â&#x20AC;&#x153;planas direct tracksâ&#x20AC;?). These turbos are still anterior enough to allow eruption of lower molars with light elastics, and clockwise tipping of the upper occlusal plane for esthetic gain. With the bite ramps on maxillary first bicuspids it allows for more eruption of lower molars than upper molars. When the cases are nearly leveled, cuspid or bicuspid turbos are repositioned anteriorly to the maxillary incisors, allowing ideal overbite protection, while maintaining incisor display, and seating the buccal segments. Anterior bite turbos are maintained until near the end of treatment, ensuring over-correction of the deep-bite. As an aside, uprighting of the anteriors is easier when the anterior teeth are not in occlusion. Posterior Bite Turbos/Pillows have evolved considerably, directed towards positive adjustments of the occlusal plane, and molar intrusion. They are used in anterior open bite cases as well as high angle cases. Upper or lower posterior bite turbos are supplemented with PT exercises (squeezing pressure on molar pillows, activating the posterior fibers of the temporalis muscles) to encourage favorable rotation of the occlusal plane and intrude molars. We suggest placing posterior turbos in the depth of the occlusal fossa rather than the cusp tips, frequently on the upper first and second molars, and adjusted to balance the occlusion. Posterior bite pillows are removed when the ideal overbite relationship is attained, so that the buccal segment relationships can be developed with finishing elastics and refined through coronoplasty. We can expect to intrude the molars 2+ mm with PT exercises.

Patient Compliance The only way we achieve “WOW” esthetics is wearing light elastics full time, immediately, and then continuing excellent compliance throughout treatment, to minimize treatment time and achieve esthetic goals. I think that Dr. John Campbell’s esthetic treatment explanation to his patients says it best, “Elastics is not a part of your treatment, it is your treatment!” We use any and all efforts that develop a collaborative relationship with patient/parent in elastic wear, explaining the impact of elastic wear on esthetic/ occlusal results, describing the adverse effects of failure to comply. We also empower the patient/parent role in achieving excellent results. Matt Brunner approaches this with NIMIT discussion (Now Is the Most Important Time) to reinforce the importance of elastic wear throughout the treatment process, using clinical photography both monitor progress and provide positive patient reinforcement.

Figure 13: Very nice final result attained in only 9 months with this approach - Courtesy Tom Pitts 2017

BEFORE

AFTER

In Summary, as our guiding principles of ILSE: Shorter elastic stretch is better than longer Groups of elastics are better than individual Full time wear is absolutely necessary (except for rainbow) Immediate (first appointment) is a must Lighter is better than heavier

Figure 14: Very nice final result attained in only 9 months with this approach - Courtesy Tom Pitts 2017

To Summarize:

We strive to develop protocols that are effective, efficient, predictable, and produce outstanding results with a more accurate and tightened slot. In “Active Early” case management, ILSE and disarticulation are critical contributors. We hope that this article will reduce some of the confusion that has existed regarding their role in our case management. Look for more innovations on both the technology and case management sides, that we will be releasing soon as the Pitts 21 system. Until next time... Drs. Tom Pitts and Duncan Brown

Figure 15 & 16: Very nice final result attained in only 9 months with this approach - Courtesy Tom Pitts 2017

Author’s Comments

Dr. Tom Pitts

Dr. Duncan Brown

“Efficiency of treatment and the quality of the final result is highly dependent on elastic wear and disarticulation. Mastering ILSE (immediate, light, short, elastics) and disarticulation will shorten treatment times, and improve the quality of your esthetic results. With the introduction of Pitts 21 appliance system, and its revolutionary slot design, using ILSE and disarticulation will be even more effective! Look forward to showing it to you!” - Tom Pitts

REFERENCES 01. Abel, M - “A brief history of orthodontics”, Am J Orthod Dentofac Orthop. 1990; 98; 176-182 02. Singh, V - Elastics in Orthodontics: a review, Health Renaissance, January - April 2012: Vol 10 (1); 49-56 03. Pitts, T - Active early Principles - Pitts Protocols Issue 2, 2015; 8 to 14 04. Schwarz, A - Tissue changes incident to orthodontic tooth movement, Int J Orthod, 1932 05. Ren, Y - Optimal Force Magnitude for Orthodontic Tooth Movement: a Systematic Literature Review, Angle Orthod 2003; 73: 86-92 06. Tong, W - Evaluation. Of force degradation characteristic of orthodontic latex elastics in vitro and Vito, Angle Orthod 2007; 77(4); 688-693 07. Gioka, C - Orthodontic latex elastics; A force relaxation study. Angle Orthod 2006: 76 (3); 475-479 09. Pitts, T and Brown, D - Overcoming Challenges in PSL with “Active early” H4. The Protocol Issue 4, 2015; 8-18 10. Pitts, T - Secrets of Excellent Finishing. News and Trends in Orthodontics, Vol 14 (April), 2009 11. Griselda, M, - Planas direct tracks in young patients with Class II malocclusion, World J Orthod. 2005 Winter 6(4); 355-368 12. Topkara, A, - Apical root resorption caused by orthodontic forces: A brief review and a long term observation, Eur J Dent 2012; 6: 445-453 13. Sergl, H - Functional and social discomfort during orthodontic treatment - effects on compliance and predict action of patient’s adaptation by personality variable, European Journal of Orthodontics 22 (2000); 307-317

NEVER MISS AN ISSUE! Read Online with your computer, laptop, tablet, or phone!

www.oc-orthodontics.com/protocol

Or, if you would prefer a physical copy, sign up online to have each issue mailed directly to you.

Read Online with your computer, laptop, tablet, or phone!

THE

OL PROT Issue

PITTS’

PROT

PITTS’

Issue 3

ucing Introd Pitts m o T Dr. ™

SAP

™

et Pla

cemen t

H4 GO ™ Self-L Aesthetic ig Brack ating et Sys tem

g igatin ™ elf-L m H4 S te s y S et Brack e ts Casnt it P . r D geme Mana

Dr. Dav Build id Herman in ’s Susta g Blocks fo inable r Market ing

’s

rnstein Dr. Be itch Big Sw

Soft Tissue Diagnosis and “SAP” Bracket Positioning

Active Early Concepts

i o n c a t e d u

SAP ™

Brack

t cemen

et Pla

Brack

OL Issue

i t y m u n c o m

t i o n o r a l a b c o l

e d u c a t i o n

c o m m u n i t y

Meet Dr. To m

Consumer e d 2.0

c o l l a b o r a t i o n

u c a t i o n

c o m m u n i t y

c o l l a b o r a t i o n

REQUEST BACK ISSUES - 866.752.0065 61

Pitts

YOU CAN HAVE IT ALL

Tom Pitts D.D.S., M.S.D. with Duncan Brown B.Sc., D.D.S., D. Ortho and James Morrish D.D.S.

ixed orthodontic appliances have slowly been losing market share throughout the world as aligner treatment has become more sophisticated. Marketing pressures from aligner giants have intensified and primary care dentists are aggressively providing “orthodontic treatment” in their offices. At the same time, mainstream orthodontics has not been progressive enough in either their fixed appliances techniques, or their ability to provide esthetic results “beyond straight teeth”. Many years ago I selected the passive self-ligating (PSL) mechanism as my fixed appliance of choice as it has helped many of us treat difficult malocclusions more easily with less extractions, less surgery, while developing stunning smile esthetics. However, for many users, it has taken too much time to finish due to loose fit of the wire in the passive slot, especially in the anterior teeth. The commonly applied clinical PSL approach was limited to increasing the arch wire size in a rectangular slot, which was inefficient, and increased applied forces to levels that were too much force for my liking.

“Creativity is seeing what others see and thinking what no one else has thought” - Einstein What do Patients really want? Dr. Jerry Watanabe spoke with me years ago about the notion that the general public believes Orthodontists or Practitioners doing orthodontics only “straighten teeth”. If we can deliver a superior cosmetic smile and outstanding improved facial esthetics, validated by excellent photos and videos of other patients, the patients will always choose “WOW” smiles (great phrase created by Dr. Nimet Guiga) and facial esthetics. They immediately appreciate the difference between straight teeth and appealing esthetics. The common response is, “You can do that? Can you do it quickly?”

Angle Bracket

It is time to rethink our role and save the specialty!

Activa Bracket

Over the last several years it became obvious to me that orthodontic thought needed a “reset”. Early on I tried .018 slotted appliances and square wires, which provided very satisfying torsional control with light forces, but was disappointing due to insufficient leveling forces and inadequate rotational control. Some years ago, I began testing .020 x .020 square NiTi and Beta Titanium wires in a .022 x .028 appliance. Both torsional control and leveling were excellent, but of course rotational control was lacking. I began thinking of the potential benefits of reduced buccal lingual slot depth to improve rotational control.

H4 Bracket

At the same time, we introduced “Active Early” case management strategies that went a long way to mitigate the challenges imposed by rigid adherence1to “straight wire theory” (which has dominated our profession since Larry Andrews’ breakthrough article2 in the 1970’s), and the limitations of rectangular slotted appliances in a PSL system.

Pitts 21 Bracket

Figure 1: Amazing changes in bracket technology.

What do Orthodontists want in their appliance systems?

Torque Control

Orthodontists want improved control of tooth movement, greater predictability, simpler “systems and processes” in clinical practice. They also want earlier control of critical tooth movement, fewer appointments and adjustments when in treatment. This includes reduced treatment times, while finishing with better esthetic results.

11˚

4˚ .020 x .020

.019 x .025 Door

Door

Bracket Body

.021 x .021 Slot

.022 x .028 Slot

Rotation Control Door

Door

.020 X .020

.014 X .025 or .018 X .025 O R .019 X .025

<1˚ Bracket Body

Bracket Body

.021 x .021 Slot

.022 x .028 Slot

Control problems that we face daily can be largely related to “finishing” in wire sizes that are less than full dimension than the designed bracket slot dimension, resulting in “play” in the system. Torsional, rotational, and tip play are factors that prolong treatment and can adversely affect the quality of the final result.

2˚

Tip Control

Bracket Body

.020 x .020

.019 x .025

<1˚

2˚

Door

.021 x .021 Slot

.022 x .028 Slot

Figure 2: Superior torsional, rotational, and tip control in the Pitts 21 “Progressive Slot” appliance attained with .020 x .020 arch wire. The 3D control attained is roughly 3X better than that present in any .022 x .028 rectangular slotted appliance with a .019 x .025 arch wire.

Slot depth, from buccal to lingual.

UL6

UR6

UL5

UR5

UL4

UR4

UR 3

Wire properties seem to have driven slot size of popular orthodontic appliances. The earliest edgewise appliances designed by Angle in the early 1920’s employed a slot height of .022 while using highly malleable precious metal arch wires. This used fairly low forces but had less torsional control. The development of more rigid steel wires permitted the reduction in wire dimension with Steiner designing the .018 slot bracket. This marked the start of the divergence between two widespread orthodontic systems (.018 and .022), with adherents to each design extolling the merits of their chosen appliance. There have even been attempts to gain the benefits of combining both slot dimensions.

L2 U

U UR1

UL1

Figure 3: In the Pitts 21 “Progressive Slot” the maximum arch wire cross section required is .020 x .020, gaining far superior 3D control than is generated by any .022 x .028 rectangular slotted appliance in a .019 x .025 arch wire. The slot retains an .021 slot OG dimension throughout the bracket set, while the BL dimension “progresses” to a bit wider in the bicuspids and molar slot for settling and space closure.

The current clinical reality is accurately reflected in a current survey of appliance preferences8 with about 55% routinely choosing .022 appliances, and only 5% a combination of .018 and .022 slot profiles.

Incremental increases in arch wire size is not an efficient means of controlling 3rd order tooth position (as a result of play in the system when the slot isn’t filled), and while “filling” the rectangular slot provides good control, the applied forces are too heavy for my liking. What is apparent is that: conventional slot profiles are not ideal, and that while mixing the slot profiles has limited advantages, they have not captured the imagination of the majority of orthodontists.

Round Wire

.018 x .018

Figure 4: Typical arch wire profiles used in the Pitts 21 “Progressive Slot” system. Patient discomfort associated with arch wire profile changes is reduced, wire progressions simplified, all while gaining superior 3D control far earlier than is possible in .022 x .028 rectangular slot system.

Reduced B/L slot dimension in the H4 bracket was a significant advance ment in improving anterior control. In the H4 bracket, reduced B/L slot dimension provided some significant clinical advantages. A few years of collective experience with the H4 bracket, in addition to refinement of “Active Early” case management protocols, and simplifying the esthetically based Pitts Broad arch wire suite confirmed many of our long-held beliefs. Early adopters were quick to appreciate the reduced inventory of a single bracket prescription. They enjoyed the simplicity of “flipping and flocking” (bracket inverting) approach to torque selection. This, coupled with the widened and esthetically based arch wires and “active early” protocols, allowed them to save treatment time with beautiful results.

Figure 5: Pre-treatment IO Photographs. cI II div 2 - Courtesy Tom Pitts

ACTIVE EARLY PROTOCOLS 1) Bracket Position 2) Slot Right Side Up or Inverted 3) Proper Disarticulation 4) Immediate Light Short Elastics 5) Archwire Sequence

.020 x .020

Figure 6: Pre-treatment pano - Courtesy Tom Pitts

6) Archwire Shape & Width

Figure 7: 4 Months - Courtesy Dr. Tom Pitts

Figure 8: 8 Months - .020 x .020 Beta Titanium - Courtesy Dr. Tom Pitts

Figure 9: 9 Months - Active early protocols with square wire - Courtesy Dr. Tom Pitts

Initial

Final - 9 Months

Figure 10: Very nice accelerated treatment with low forces and no root absorption. - Courtesy Dr. Tom Pitts

This experience also pointed out some design concepts that could benefit from further refinement. Having 3rd order pressure on the slide was an issue and we still couldn’t fill the slot occlusally/gingivally with the biologically sensitive forces. Rectangular wire treatment had grown in disfavor with me and many other orthodontists. I am excited to introduce you to a “revolutionary” development in appliance design, the “Pitts 21” appliance, incorporating the “progressive slot” concept and “square wire finishing”. The “Pitts 21” appliance is a “next generation” PSL appliance designed to enable the Orthodontist to efficiently attain effective tooth movements that are more predictable, earlier in treatment, using gentler forces and fewer arch wire changes than ever before. When coupled with Active Early case management strategies, wonderful esthetics can be developed very efficiently.

Figure 11: Pre-treatment EO Photographs - Courtesy Dr. Tom Pitts

“Pitts 21” system affords the potential for a true 4 wire system, with superior 3D control, and can deliver outstanding smile esthetics using our protocols. In vitro research confirmed our clinical experience that reduction of the BL slot dimension facilitates generation of clinically effective torsional forces in smaller arch wire profiles and that plastic deformation of the slide under repeated cycles or high torsional loads can and do adversely effect performance of H4.

Figure 12: Pre-treatment IO Photographs - Courtesy Dr. Tom Pitts

Square Wire Finishing is Exciting! For years I have minimized the .022 rectangular slot problems by using .020 x .020 square wires and then adjusting the wires to correct the ro

Figure 13 SAP bracket position*, Flipped Mx 2-2, posterior disarticulation, ILSE TTB 3/16 2.5 oz, Anterior Rainbow 5/16 2.5 oz, PT Squeeze exercises - Courtesy Dr. Tom Pitts *Tooth 22 is bonded for initial alignment but will be removed due to tooth size

tations. This works well, but is not really efficient, so further refinement in the slot profile was required. I am grateful to OC Orthodontics, and the design engineers for embracing a visionary concept and releasing the Pitts 21 “Progressive Slot” System, the first labial fixed appliance that will allow “square wire finishing”. The system leverages “Active Early” Case Management practices, the Pitts 21 “Progressive Slot”, and esthetically optimized Pitts 21 Broad Arch Wire Suite to provide better control, earlier in treatment, more simply, and with far lighter forces than any rectangular slot based system. In the Pitts 21 .021 x .021 slot, torsional couples are developed between the rigid parts of the bracket body, so we don’t have to worry about slide deformation.

Initial Bonding

2 Months

3 Months Figure 14: Progress IO Photographs* - amazing control and progress in only 7 months - Courtesy Dr. Tom Pitts *Notice the torsional control of the upper anterior teeth, excellent 3rd order control of lower incisor position and arch development

The bottom line is: these improvements in appliance design generate the most effective results plus sound case management strategies = Pitts 21 system

The Pitts 21 “Progressive Slot” is just better!

6 Months

7 Months

This (patent pending) slot profile provides far superior 3D control throughout the bracket set, allows sliding of the posterior teeth to facilitate space closure, while facilitating BL settling of the occlusion in the buccal segments. I’ve been asked about root end resorption possibly associated with our decreased treatment times and more rapid tooth movement, but we have not found this to be the case. It has been a common experience that more root end resorption occurs with heavier forces than with gentle forces applied earlier in the treatment cycle (see panorexes).

Initial Bonding

2 Months

3 Months

6 Months

7 Months

11 Months

Figure 16: Progress IO Photographs* - amazing control and progress in only 11 months - Courtesy Dr. Tom Pitts * progress could have been quicker but given the presence of the supernumerary lateral, went well

Initial Bonding

11 Months

Figure 17: Excellent control of vertical tooth position, which improves VID (Vertical Incisor Display) as a result of Active Early Case Management strategies - courtesy Tom Pitts

Initial Bonding

11 Months

Initial Bonding

11 Months

Figure 18: Excellent esthetic outcome in less than 11 months of active treatment - Look at the positive change in facial taper courtesy Dr. Tom Pitts

The Pitts 21 “Pitts Broad” Arch Wire Suite

Summary & Case Management Considerations

The Pitts 21 arch wire suite is comprised of a selection of arch wires in the Pitts Broad esthetically optimized arch forms, which reduces wire shaping required for optimal esthetics, and enables “square wire” finishing. The “Progressive Slot” provides the potential to utilize a 4-wire sequence during treatment. This reduces inventory, enables superior 3D control earlier in the treatment cycle than rectangular slot based systems and utilizes fewer arch wire profiles, simplifying wire progressions and improving efficiency. When the .021 slot is “filled” with a Pitts Broad arch form early, desired development happens.

The “Active Early” Case Management strategy, combining the SAP (Smile Arc Protection), VID (Vertical Incisor Display), and VIP (Vertical Incisor Position) bracket position. It also includes ILSE (Immediate, Light, Short, Elastics) and disarticulation, aesthetically based Pitts Broad arch forms. “Flipping and Flocking” approach to appliance selection and can provide significantly more esthetic clinical results. In Pitts 21 we have a fixed appliance system that delivers superior control in all 3 planes of space, simplifies mechanics, reduces applied forces to improve patient comfort and does it in a fairly predictable manner.

Rather than rely on incremental increases in arch wire profile to increase delivered forces in the system as required in rectangular slot systems, the Pitts 21 “Progressive Slot” system utilizes a variation in metallurgy to increase force. We are in full size NiTi by the 3rd wire. This approach provides effective tooth movement earlier. Only when faced with very narrow arches, is a widened .019 x .019 Stainless Steel arch wire used, but most of the time, this can be managed by shaping a .020 x .020 Beta Titanium arch wire early and thoroughly while using early, light cross bite elastics as necessary. Torsional force loads are reduced to 60% to 70% of those delivered in rectangular wire system over large working ranges, increasing patient comfort, and are seemingly kinder to the biology. Reduction in OG dimension of the bracket slot when combined with a .020 x .020 wire size delivers gentler forces with only a 7% reduction in rigidity (for tipping control), allowing efficient space closure, and broadening of the arches.

Our mission with Pitts 21 and the protocols are consistent, predictable, and superior esthetic clinical results delivered in shorter treatment times, fewer appointments, and more gently. Both the Patient and the Orthodontist benefit. As we say, “you can have it all.” The specialty hopefully does not have to rely on a 3rd party technological gatekeeper.

We encourage and support those orthodontists that strive to achieve the most healthy and beautiful esthetic smiles. Pitts 21 (with our protocols) is a step in that direction. We have more innovations in the works so stay tuned…

Initial Bonding

11 Months Figure 19: Excellent occlusal outcome in 11 months of active treatment. Molar bite pillows were just removed and no TADS were utilized, just light elastics - Courtesy Dr. Tom Pitts

Phase

Initial

Wire

.014 Thermal Activated Nickel Titanium

Working .018 x .018 Ultra-Soft Thermal Activated Nickel Titanium

.020 x .020 Thermal Activated Nickel Titanium

Finishing .020 x .020 Beta Titanium

Optional Archwires .019 x .019 Stainless Steel

.019 x .019 Beta Titanium

Extra Width & Extraction Cases

Auxiliary Adjustable Wire

Figure 20: Guidelines for wire selection in Pitts 21 “Progressive Slot” system. Unique to the system are Ultra-Soft .020 x .020 arch wires, which allow repositioning of brackets without losing 3D dimensional control.

Figure 21: Pre-treatment EO Photographs - Courtesy Dr. Jim Morrish

Figure 22: Pre-treatment IO Photographs - Courtesy Dr. Jim Morrish

Figure 23: Progress IO Photographs* - amazing control and progress in only 2 months. Pitts 21 appliance in place with disarticulation and immediate light elastics. - Courtesy Dr. Jim Morrish * patient has fixed appliances removed for a family wedding, and was so pleased with the end result she did not have them replaced * only Mx 2-2 and Md 2-2 are Pitts 21 brackets

Initial Bonding

2 1/2 Months

5 Months

3 Months

6 Months

Figure 24: Progress IO Photographs* - amazing control and arch development - Courtesy Dr. Jim Morrish * patient has fixed appliances removed for a family wedding, and was so pleased with the end result she did not have them replaced

Initial

6 Months

Figure 25: Excellent control of vertical tooth position, which improves VID (Vertical Incisor Display) as a result of Active Early Case Management strategies - Courtesy Dr. Jim Morrish

6 Months

Figure 26: Excellent esthetic outcome in less than 6 months of active treatment - Courtesy Dr. Jim Morrish

Initial

6 Months

Figure 27: Excellent occlusal outcome in less than 6 months of active treatment with never more than 2.5 oz. elastics and Pitts 21 appliance and inverted brackets on upper anteriors. - Courtesy Dr. Jim Morrish

Author’s Comments

Dr. Tom Pitts

Dr. Duncan Brown

Dr. James Morrish

“Today’s patients want superior esthetic results faster. Orthodontists want predictable performance, better control, sooner, and predictability with gentle forces. With Pitts 21, Pitts Broad arch forms, and “Active Early” protocols both patients and doctors can have what they want. You can truly, ‘HAVE IT ALL”. - Tom Pitts

REFERENCES 1 Pitts, T and Brown, D - “Active Early” Principles, Pitts Protocols 2015 (2); 8 - 15 2 Andrews, L. - The six keys of normal occlusion: AJO, 1972; 62: 269-309 3 Badawi, H - Torque Expression in Self Ligating Brackets. a systematic review: Am J Orthod Dentofacial Orthop 2008 May; 133(5): 721-728 4 Meling, T - On mechanical properties of square and rectangular stainless-steel wires tested in torsion: Am J Dentofacial Orthop 1977 March; 111(3); 310-320 5 Pitts, T - Active Early Principles - Pitts Protocols Issue 2, 2015; 8 to 14 6 Pandis, N - Moments generated during simulated rotational correction with self-ligating and conventional brackets, Angle Ortho, Vol 78 (6) 2008; 1030 - 1034 7 Franco, E - Comparative study of torque expression among active and passive self-ligating and conventional brackets, Dental Press Journal of Orthod. 2015 Nov-Dec; 20(6): 68-74 8 Banks, P - The use of fixed appliances in the UK; a survey of specialist orthodontists, J Orthod 2010, 37: 43-55 9 Romanyk, D - The effect of buccal lingual slot dimension size on third-order torque response, European Journal of Orthodontics, 2016, 1-6

Rev. B 02/20/18