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Tip edge technique

Contents

Introduction Tip edge concept Tip edge brackets Tip edge auxiliaries Differential Straight Arch Technique Stages of treatment Final Finishing Conclusion References

Introduction
Since the 1900 Angle introduced various appliances : Angles E-arch Pin and Tube appliance(1910) Ribbon arch appliance (1915) Edgewise appliance(1925)

Edgewise appliance

Labially facing horizontal slot 3-dimensional control over tooth Very high forces were used Anchorage depends on extra oral forces No provision for closure of posterior spaces Arch wire slot restricts the anteroposterior correction of dental arches

Begg appliance
During the early 1930s, P.R Begg reverted to the use of ribbon arch brackets Permitted free tipping followed by controlled uprighting Use of round wires Use of differential forces(2 oz) Demands on anchorage units was reduced However the vertically facing slot had the following limitations: Hindrance in manipulation Reduced mesio-distal control

Straight wire appliance

1970s Dr Lawrence Andrews introduced the Straight Wire bracket system Concept of Preadjusted applianceTip, torque, in-out compensations for each tooth was available.

Limitations of conventional Straight Wire bracket

Moving teeth apex first generates maximum anchorage resistance Torque control - unwanted reciprocal torque reaction in adjacent teeth Full expression of torque not achieved- torque slop due to play between bracket and arch wire

Tip edge concept

Peter C Kesling decided to combine both the techniques Modified a straight wire bracket ,to create Tip Edge bracket Technique was first introduced at the KeslingRocke Orthodontic Centre,Westville,Indiana,USA in 1986.

Differential force technique: initial crown tipping followed by controlled root uprighting with straight arch wires (differential tooth movement with straight arch wires). Therefore it is known as the Differential straight arch technique Arch wire slot permits initial crown tipping mesially or distally and faces horizontally, the slot and bracket are termed Tip Edge

Features of tip edge appliance

Labially facing arch wire slots improved manipulation with elastomeric ties Light forces(2 oz) Reduced strain on anchorage With a rectangular slot ,a 3-D control was afforded Slots open and close during treatment for maximum ease of arch wire change and minimal discomfort Facilitated intrusion of teeth.

Tip edge brackets


Kesling determined that : It is necessary for each tooth to tip either mesially or distally not both directions All teeth tip distally except those distal to the extraction sites-which tip mesially Anchor molars should remain upright throughout Rx.

Diagonally opposite corner were removed Permits desired distal crown tipping Preadjusted in 3 dimensionstip,torque,in & out built in Slot size-0.022x0.028

Central ridge

Lateral extensions
Uprighting surface

Tipping surface

Profile view

Occlusal view

Design features

Slot size: 0.022X0.028 Vertical slot: 0.020x0.020- to accept rotating or up righting springs, power pins ,jigs etc. Both the gingival and incisal ends are chamfered to facilitate the insertion of auxiliaries from either direction. Lateral extensions- for rotational control hidden behind the arch wire which is esthetic. In and out compensation-eliminates the need for lateral, bicuspid or molar offset Torque built in base Tip built in face

Slot permits initial M-D tipping ,this prevents bowing of arch wire during retraction/space closure and automatically enhances anchorage.

Uprighting surfaces of the slot determine the final tip angulations reached with an uprighting spring. These surfaces can also control torque if an edgewise arch wire is used.

Types of bracket
Narrow metal tip edge bracket

Twin metal tip edge bracket

Narrow ceramic tip edge bracket

Twin version of bracket - 018 or 022 slot size Known as Freedom brackets Disadvantages :
Unaesthetic Extra bulk-occlusal interferences and accidental debonds Mechanical disadvantage when Side Winder springs are added

Tip edge brackets for first premolar extraction cases

Tip edge brackets for second premolar extraction cases

Tip edge brackets for non extraction or first molar extraction cases

Preadjusted in 3 dimensionstip,torque,in & out built in

Tip and torque values for maxillary brackets

Tip and torque values for mandibular brackets

Placement of tip edge attachments

Positioning jigs used for bracket placement

Positioning jigs used for bracket placement

Mid crown position is recommended (Parkhouse) Bracket should be aligned with its vertical axis parallel with the long axis of the tooth Mesio-distally at the midpoint Height of the bracket should be at vertical midpoint of the fully erupted clinical crown

Jigs can be modified by cutting off the horizontal section leaving only straight vertical markers

Rationale behind a mid crown bonding

Prescribed torque value in the bracket base is effectively expressed Initial tipping will be more by the incisal placement of the bracket but it also requires an increased amount of root uprighting Side Winder springs are placed at greater mechanical disadvantage if the distance between the point of rotation and the root apex is increasedresulting in loss of eficiency Also mid-crown position reduces occlusal interference therefore decreases the number of accidental debonds

Molar tubes

Parallel to occlusal surfaces Upper molar tubes placed at the same level as the bicuspid

Universal premolar tip edge brackets

Similar tip and torque for 1st and 2nd premolars So, possible to have just 2 upper and 2 lower bicuspid brackets. Can be switched from R to L side to provide clockwise or counterclockwise crown tipping.

Identification of brackets Arrow - direction of tipping Premolar jigs are modified by the addition of a 90 angle at the tip of the jig which indicates the direction of tipping Origin from Queens University ,Belfast called as Irish jigs

Auxiliaries used in Tip Edge Technique


1.Molar tubes
Keep molars upright and permit free sliding of arch wire. Three types: Single round tube with torquing flap Combination edgewise(0.022X0.028) and round tubes(0.036) Combination edgewise and flat oval tube for increased bucco-lingual control

Single round tube with torquing flap

Combination of rectangular and round tube

Combination of rectangular and oval tube

Rectangular slot is at the same level as premolar brackets. Permits the placement of straight arch wire Round tube dimensions: 0.036inside diameter,0.250length Rectangular tubes are of Easy-Out R TP design with the posterior inner lumen slightly flared towards the occlusal. Facilitates archwire removal when a cinchback has been used

2.Tip edge rings

Elastomeric rings designed to function with tip-edge brackets Designed to retain archwire and prevent mesial and distal tipping during Stage III Lingually facing lug on either end of the crossbar wedge between the archwire and the bracket to control mesiodistal inclination of the tooth

Straight Shooter (ligature gun)

Advantages Less time consuming Places less pressure on the tooth ,more comfortable for the patient

3.Rotating Springs For correction of rotation Preformed from 0.014 ss wire Inserted from gingival aspect

4.Mesiodistal uprighting springs

Optimal means to upright teeth mesiodistally Standard and Side-winder designs Provides localised tip control of individual teeth without archwire modification Fabricated from 0.014 ss archwire

Side-winder springs

Coils rest on the labial surface of the bracket Improves:


Esthetics Hygiene Choice to insert from gingival or occlusal aspect Mechanical advantages as centre of the coil is concentric with the centre of the bracket

Invisible Side Winder springs


Wire of spring lies on archwire and bracket Advantages: Retained in position by the elastomeric module, in addition to its own spring pressure Enables modules to be changed if necessary, during the root uprighting process without removing springs

Because bulky hook has been eliminated, spring arm has a wide range of activation

Direction of insertion

Occlusal and not gingival Masticatory forces coming occlusally are deflected harmlessly off the coils of a correctly inserted spring, keeping these in close proximity to the bracket face. If inserted from gingival, occlusal forces might distort them labially away from the bracket spoils the action of the spring as well as causes discomfort

Identification of spring

Spring arm points in the direction towards which the occlusal tip will rotate

5.Bilevel pins

Used to capture auxiliaries behind tie wings of the bracket Heads of pins function to retain the auxiliaries and to tie ligature When used with open coil spring; eliminates the need to use vertical loops or to remove main wire to remove coil

6.Power pins Ideal auxiliaries to engage elastic or elastomeric Can be inserted from occlusal or gingival Low profile head with 15 inclination reducing the need for right and left pins Can be inserted or removed while both ligature and archwires are in place

7.E-links

Elastomeric links stamped from thermoset material Less hydrophilic than thermoplastic material Available in graded lengths E1to E4 smaller size with no tabs E4 to larger sizes with tabs

8.Archwires

U/L 0.016 round ,hard,resillient wires Vertical loops may be bent into the initial wire Small segment of co-axial wire 0.014 or 0.016 NiTi as auxiliary wires for alignment Advantages:

Rapid anterior bite opening and improve molar control Reduces the number of archwires required to treat a specific case

0.022 SS used during space closure and final uprighting or torquing Rectangular archwires retained in brackets with tipedge rings offer the final expression of tip and torque predetermined in the bracket slot 0.0215X0.028 SS archwire are preferred for final finishing

Concept & Function


Bite opening

Tip-edge slots facilitate intrusion of teeth along the path of least resistance without creating lateral root movementsopen deep bites without the need for extra oral forces Intrusive forces from: Properly bent 0.016 high-tensile SS wires, Use of Light inter maxillary elastics(2oz).

Retraction and Space closure without loss of vertical control

Binding between slot and archwire In the canine area incisal deflection of wire

No binding or incisal deflection of wire in tip edge slot

Dynamic arch wire slot Tip edge slots become larger as the teeth tip. The vertical dimension within the slot continuously increases with each degree of distal tipping.

Inter bracket distance

The tip edge bracket provides automatic mesiodistal tip control The tip edge bracket with its propeller shaped archwire slot can provide 100% interbracket distance in both planes. As the crown is tipped distally, slot size increases, this permits passive engagement of full size SS wire with zero flexing.

Advantages

No binding or archwire deflection during retraction Ease of stepping up of archwire size No inadvertent mesial or distal root movement Ease of placing rectangular archwires when third order discrepancies exist between archwire and slot. No need to use NiTi archwires to avoid discomfort and accidental debonding

The Hammock Effect

When a ligature (especially steel) is used to retain the archwire a hammock effect is created that tends to parallel the archwire with the gingival and occlusal edges of the tie wing tips. This could influence mesial /distal inclinations Steel ligature when tied loosely minimizes the hammock effect.

Anchorage consideration

Extra oral anchorage is not required with Differential Straight Arch Technique Forces are so light that adequate anchorage can easily be formed within the mouth. Binding (as in edgewise slots) is nonexistent during retraction. In DSAT,archwires move distally with anterior teeth retraction and premolars are not bracketed during Stage I. Therefore no sliding friction occurs---no additional strain on anchorage. Only friction is in molar tubes which is minimal because tubes are long with large diameter.

Axial inclination control Controlled root movement which is


Selective Physiologic Predetermined

Selectivity

Selective axial tooth control w.r.t time and location Tip or torque is achieved by addition of SideWinder springs to the teeth requiring correction Rest of the teeth are left undisturbed Application of force is selective and adjacent teeth are not round tripped Promotes stability and patient comfort

Limitation

Design of the bracket automatically limits the degree of M-D uprighting Uprighting continues until the control surfaces within the slot strike the upper and lower surfaces of the archwire. Torquing is also limited and ceases even though the spring remains active-determined by the torque built in the bracket

Physiologic

Light and continuous forces are transmitted through the auxiliaries Design of tip edge bracket prevents delivery of high third order torque forces from flexed rectangular wire

Advantages of Tip Edge brackets

Over conventional edgewise brackets Eliminates undesired force couples to promote rapid bite opening and prevent midline discrepancies Anchorage problems are eliminated as space can be closed with light forces and minimum wire deflection. This results in diminished anchorage demands and increased vertical control. Permits free crown tipping followed by controlled uprighting Can reposition teeth and jaws with light forces and still maintain total control over their final positions.

Over Begg brackets

Horizontally facing archwire slots facilitate initial archwire engagement especially on rotated teeth. Elastomeric ties provide a cushion or flexibility that enhances patient comfort and reduces the chances for bond failure In out compensation eliminate the need for molar (or other) offsets. Slot designs causes automotive shift from tipping to bodily movement at the predetermined angle and increase anterior anchorage to encourage mesial movement of posteriors Programmed Differential Mechanics Labio-lingual root torque from rectangular wires possible.

Three stage of Treatment


Stage I Objectives

Open (or close) the anterior bite Eliminate anterior crowding Close the anterior spaces Overcorrect the rotated cuspids and bicuspids Correct posterior cross bites Correct any mesiodistal malrelationships of the buccal segment as necessary

Stage I archwires 0.016 S-S wire Preformed wires

Fabricated from 0.016 Bow flex archwires These are size graded according to the distance in mm between the cuspid circles

Intermaxillary circles

Bent in a vertical plane or inclined slightly labial located 1mm mesial to canine bracket Anterior portion of the circle is labial to the archwire to facilitate engagement of distally directed ties or elastics

Advantages of cuspid circles: Easier to bend Can be rolled mesio-distally Less chance of breakage Disadvantage: Less retention of elastic if bent too small or tightly

Cuspid ties

Prevents canine from sliding distally along the wire Not to be used when aligning crowded anterior teeth with co-axial or NiTi sectional wire

Bite opening mechanics


Anchor bends placed 2 mm mesial to molars If reduced overbite or an open bite is present at the start of the treatment, reduced degree of anchor bends are placed. Also depends upon the angulation of molars-if molars are tipped mesially, reduced angulation required.

Intermaxillary elastics

Use of light Class II elastics (1 to 2 oz) Worn full time from upper cuspid circles to the distal ends of lower arch wire or from molar hooks Overbite reduction is more effective with a more distal application of elastic to the molar which better resists distal crown tip and encourages fuller expression of the anchor bends to the anterior segment

Outrigger appliance

To encourage elastic wear Auxiliary is threaded over an archwire formed with appropriate bite opening bends or sweeps but no intermaxillary circles Has two elastic hooks that extend labially when elastics are not engaged Hooks act as a painful reminder

Stage II
Objectives:

1.Close any posterior spaces 2.Maintain all corrections obtained during stage I Edge to edge relationship of anterior teeth Anterior space closure Over rotated cuspids and or bicuspids Corrected mesiodistal molar relationship

Stage II archwires

0.020 or 0.022 hard round S-S wire Reduced anchor bends Molar offset (vertical) to compensate for the more gingivally placed round tube Heavier archwires function as retainers to maintain arch form and bite opening achieved during stage I Heavier wires can better withstand the forces of occlusion-less likely to get distorted

Remove anchor bends, place sweep in the archwire Upper- increased Curve of Spee Lower- Reverse Curve of Spee Insert wire into rectangular tube (Parkhouse)

Derotation of molar 1mm Molar offset and 10toe-in for final visit of stage II Initial stages no need to place these bends as it increases friction

Levelling of molar

Tipped back molars should be leveled to allow the placement of rectangular archwires Antitip bend of 10 opposite premolar-molar contact point Ensures seating of the distal cusp of tipped molars Can be combined with offset and toe-in

Space closure By E-links form buccal hook on the first molar to cuspid circle Available in graded lengths Usually E-6 or E-5 is selected

Putting on the brakes:

Available space can be closed by protraction of the posterior teeth mesially : a. Application of passive uprighting spring on the canine, b.Tipping surface of the tip edge arch wire slots striking the archwire c. Use of rectangular wire

Automatic canine rotational control during retraction

Forces are not applied labial to the surface of canines. Instead pressure is applied at their contact point with the lateral incisor

Stage II checks

Intervals 6-8 weeks Observe space closure Cut distal ends Check molar widths Labial segment position and inclination excessive Check midlines Check interarch-relationship Avoid overcompression

Pre Stage III


To align the premolars Rotate anchor molars Level the occlusal plane Original 0.016 round archwire is used Increased flexibility helps to level occlusal plane and elevate premolars Light lingual elastomerics to derotate molars Duration-- 6-8 weeks

Stage III Objectives:

Maintain all corrections achieved during stage I and stage II Achieve desired axial inclination of all teeth
M-D inclinations are corrected by use of uprighting springs Lingual or labial root torque is achieved through torquing auxiliary Tip edge rings maintain and/or influence teeth in final tip angulations

Stage III archwires


0.020 or 0.022 hard round S-S wires- to counteract the reciprocal forces generated by auxiliaries Heavy wire functions as retainer Separation of root moving forces from the archwire permits the precise application of torque and uprighting pressures Maxillary archwire slight constriction is placed in the archwire (except in RME and class III malocclusion) No anchor bends but a gentle curve of spee is given to deliver a gingival force

Maxillary archwire

Mandibular archwire Slightly expanded Slight anchor bends or Reverse curve of spee Vertical offsets to compensate for the level of molar tube In class III Rx widen the maxillary arch and narrow the mandibular Cuspid ties are normally not used to allow uprighting of teeth to take place.

Mandibular archwire

Stage III Auxiliaries Torquing auxiliary

Conventional torquing auxiliary Torque bars Curved ribbon sections of 0.022 X0.028 Ni Ti formed with 20 of torque. Individual root torquing auxiliary

Nickel titanium torque bar

Individual Root Torquing auxiliary

Deep Groove brackets


For use with torque bars On the maxillary central incisors Conventional preadjusted edgewise slot cast into the bottom of tip edge slots. During stage I and II ,cap fills the groove In stage III,cap is removed and the torque bar is ligated tightly into the Deep groove under the round archwire.

Uprighting with Side Winder springs

Third order movement by second order force from a Side Winder spring in the presence of a rectangular archwire

Indications for rectangular archwires

First proposed by Richard Parkhouse Simplifies treatment and increases stability during all uprighting and torquing procedures To establish molar root torque

Preparation for rectangular Stage III

After completing stage I, 0.016 wire is modified with vertical curvatures instead of anchor bends ,to avoid the use of vertical offset Wire is inserted into the rectangular tube instead of round tubes. This elevates premolar brackets to the level of rectangular tube If premolars are too gingival initially place the wire into round tube, then into rectangular tube. Once premolars are aligned ,shift to 0.020 or 0.022 round wire

Rectangular stage III wire 0.0215X0.028 rectangular archwire with similar curvature as in round wire Crimpable hooks are placed midway between canine and lateral incisor brackets facing gingivally

Mild Curve of spee in maxillary archwire and RCS in mandibular archwire If initial open bite or reduced overbite, flat archwires are made Compensatory buccal crown torque in anterior segment to restore zero torque

Pretorqued archwire
0.0215 X 0.028 rectangular archwire with lingual crown torque (5 maxillary,8 mandibular) for deep bite cases Centre line markings:
Blackmaxillary Red--mandibular

Round or Rectangular archwires??

Severe anteroposterior discrepancy round wires for stage III Also when molar torque or selective labiolingual root positioning of canine or mandibular incisor is not required Rectangular wires should not be used until the torque has been established by use of torquing auxiliary

Final finishing

Use of rectangular wire during this stage Beginning with 0.019X0.025 ,then 0.021X0.028 for total tooth control. Rectangular wires should pass through the rectangular tube Tip edge rings can maintain or even capture the tip angles in all bracket slots

All stage III objectives ,especially anterior root torque must be entirely completed before going to rectangular finishing archwires

Second molar alignment During Stage III, preliminary alignment by a simple sectional device suggested by Dr Tom Rocke. Straight 0.016high tensile S-S sectionals It runs through the channel of the gingival tie wing of the first molar, without being attached to it. Mesially ends with a small occlusally inclined loop which hooks over the main archwire

Occlusal seating 0.019X0.025 braided archwire and seating elastics

3 weeks later

Sectioning the main archwire


Cut distal to each canine Molars and premolars, canine to canine tied together to prevent spacing Light rhomboid elastics to allow settling of buccal section

Tooth Positioners Pre-Fit positioners come in different sizes (for extraction and nonextraction cases) Inappropriate for individual tooth size discrepancies

Conclusion

The tip edge bracket provides varying degrees of tooth control not previously available in an edgewise type bracket. Control ranges from a simple one-point contact and 100% interbracket distance with a round archwire to predetermined control in three planes with rectangular arch wire and a Tip-Edge ring. It also offers advantages over ribbon-arch (Begg) brackets through ease of manipulation provided by the horizontally facing slot plus predetermined limitation of initial crown tipping and control of final root uprighting.

References

Tip Edge guide and the Differential Straight Arch Technique. Peter C Kesling Orthodontics by Graber Vanarsdall. Tip Edge Othodontics.Parkhouse Dynamics of the Tip-Edge bracket.PeterCKesling.AJODO1989;96:16-25 Treatment with Tip-Edge brackets and Differential tooth movement.KeslingPC,Rocke TR,KeslingCK.AJODO1991;99:387-401 The Tip Edge Concept:Eliminating Unnecessary Anchorage Strain.Kesling CK.JCO1992;26:165-178.

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