FACHLICH Passive Self-Ligation 2014/WCO.pdf · No. 3-4 2015 (c) J ompr entof rthod rtho OO mf entof rthod ieferortho UOO) 47 Passiv Self-Ligation FACHLICH How ligation method fits

No. 3-4 / 2015 (c)J. Compr. Dentof. Orthod. + Orthop. (COO) Umf. Dentof. Orthod. u. Kieferorthop. (UOO)

46

FACHLICH Passive Self-Ligation

Dr. Tom Pitts, Reno, NV (USA)Dr. Duncan Brown, Calgary (Kanada)

Introduction

“Everything should be made a simple as possible but no simpler” - Einstein

As orthodontic clinical procedures and esthetic prefe-rences continue to evolve, the clinical approaches that we rely on today are quite different that those earlier generations of Orthodontists used frequently.1

Frequency of four bicuspid extraction protocols popu-lar when profile reduction was desirable has diminished with non extraction treatment 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 con-cept 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 expression.4.

Inaccurate bracket placement, variation in tooth struc-ture and tooth facial morphology, variations in the ma-xilla/mandible skeletal relationships, tissue rebound, mechanical deficiencies in the appliances3, and varia-

Overcoming Challenges in PSL with Active Early

ble threshold of biological activation are all factors af-fecting the outcome. Refinements to the appliance du-ring this time have largely focused on minor 3rd order adjustments with the goal of attaining greater predicta-bility of desired 3rd 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 movement.4

A sound understanding of the technology used on a daily basis is a common feature of great case mana-gers. Each Orthodontist chooses an appliance system believing that it will help to attain good results. Unfor-tunately, limitations in the manufacturing processes combine with strongly held misconceptions derived from “straight wire theory” to make case management more difficult. Too often, good clinical results are attai-ned “in spite of the technology used, not because of it”. Today I would like to briefly examine the role the appli-ance, some widely held case management approaches, and suggest a few simple strategies that can make treatment more efficient, more consistent, and impro-ve the quality of the end result. Far too many treatment outcomes today have excessive upper incisor procli-nation.

Abb. 1

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

Abb. 2

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

Abb. 3

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


47

Passiv Self-Ligation FACHLICH

How ligation method fits into this context:

While there has been much debate on the relative me-rits of ASL (Active Self-Ligating), PSL (Passive Self-Liga-ting), and Traditional Ligation, these principles apply to all fixed orthodontic appliances regardless of ligation type. It is a common misconception that I care what ligation system an Orthodontist chooses to use. I do not, as long as excellence in esthetics and occlusion is achieved as the clinical result. The fact is that the “best orthodontic results are produced by the best case ma-nagers regardless of the appliances they use”.

I have used PSL appliances exclusively for the last 15 years. I prefer this ligation method for a number of re-asons:

• Certainty of ligation: With PSL self-ligating bra-ckets 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 feature is espe-cially valuable with the expanded use of auxiliaries in orthodontic practice, as reducing variability in cli-nical delivery will increase efficiency.

• Improved hygiene: Elimination of either steel liga-ture “pigtails” or elastomeric ties is a potential asset in terms of improving hygienic outcomes . Wearing fixed appliances reduces potential for excellent hy-giene so that changes in the bacterial quantity and quality need to be addressed with a disciplined hy-giene control program to ensure beautiful results.6

• Faster wire changes: It is very easy to engage light wires in the PSL mechanism while reducing the ad-verse effects of RTS (Resistance to Sliding), such as flaring, early in treatment.

• Quick out of the gate: In speaking with Orthodon-tists around the world, it seems that their PSL expe-rience is pretty consistent with very positive expe-riences in early treatment and greater difficulty in finishing. These anecdotal experiences correspond well to research demonstrating that the PSL mecha-nism produces less friction in smaller round wires wi-thout tipping and misalignment, and that the advan-tage largely disappears in larger rectangular wires.7

• 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 where there is minimal RTS.

Many good “in vitro” studies demonstrate that PSL me-chanisms display less RTS than either ASL or Traditional Ligated systems8 in round wires. This fact 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 potential benefits have been supported by rigorous clinical research.

Today I use the H4 bracket, a precision “straight wire” PSL appliance that incorporates a number of unique features in 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 leve-rages the unique features of the H4 appliance, overco-mes many misconceptions imposed by rigid adherence to “straight wire theory”, and addresses the shortco-mings common in PSL mechanics (Figure 4).

In PSL where engagement of the wire and slot is entire-ly dependent on the mechanism rather than on elasto-meric ties or steel ligature ties, so it is of paramount im-portance that the manufacturing tolerances are precise to ensure predictable performance of the appliance.

Abb. 4

Pitts „Active Early“ approach to case management uses lighter forces, applied for longer duration, earlier int he treatment cycle to improve control of both axial inclination and transverse arch development


48


Manufacturing tolerances matter:

Early literature on the potential for torsion created in the appliance was based on theoretical mathematical models and discussions. When conclusions derived from this process are applied clinically, the results are frequently disappointing. Further basic science re-search identifies manufacturing tolerances as one of the reasons.

Charles Burstone clarified the distinction between axial inclination (the buccal lingual inclination of the teeth), bracket slot (labio-lingual) angulation (incorrectly ter-med torque), torsion (the forces resulting from a couple within the system), and torque expression (the result of torsion). For clinicians, primarily concerned with torque expression, the ability of the appliance to generate appropriate forces and moments is of primary impor-tance, even after patient specific factors are taken into account. Research into manufacturing tolerances of both the brackets and wires have discovered several important facts that have direct clinical application in the areas of slot size, bracket rigidity, wire dimension, and wire corner radius:

• Most Orthodontic slots are very inconsistent: Many bracket slots have rounded corners, slot walls that are not parallel, rounded internal line angles, varia-ble slot taper, slot dimensions that are oversized up to 27%.9 This variation effects generation of torsion developed within the slot.

• Orthodontic brackets vary in rigidity: Orthodontic brackets are not rigid, but can deform in an elastic (returns to original shape after torsion is removed) or plastic (permanent deformation) manner when torsion is applied. Surprisingly, these deformation can and do occur within torsion ranges commonly applied in clinical practice,10 and will effect torsional expression.

• Orthodontic wires are variable in dimension and performance: Orthodontic wires vary in actual cross sectional geometry and material properties which effect torsional stiffness and therefore torque ex-pression.11 The clinical relevance this research is that even at 25 degree of twist (a clinically significant

twist), insufficient torsion may be created effectively change the axial inclination of teeth.

• Corner radius of wires are variable: Edge bevel on orthodontic wires are remarkably variable, and signi-ficant as the angle of engagement is dependent on the corners of the wires engaging the super and infe-rior walls of the slot. The edge bevel contribution to engagement angle can range from .2 to 13 degrees depending on the bracket/wire combinations.12 The worst performer in this regard is found in Beta tita-nium wires, which is the wire generally favored for increasing torsion through wire bending.

For the most part, orthodontic manufacturers have supplied us with “orthodontic slots that are too large, orthodontic brackets that are too soft and orthodontic wires that are too small with corner radius that are too large”. This makes predictable performance of edge-wise appliances a challenge.

We favor the H4 appliance from OrthoClassic because of the consistency and precision in its MIM manufac-turing (.001 tolerances), dense metallurgical structure (adding to rigidity), and reliable rigid slide (adding to consistent slot dimension) in our preferred PSL mecha-nism.

Misconceptions and common practices that compli-cate things further:

When an inconsistent appliance is combined with com-mon orthodontic clinical management practices based from misconceptions regarding how the appliance should behave, treatment outcomes can be adversely affected.

• Contemporary fixed orthodontic treatment is usually completed in wire sizes that are less than full dimen-sion13 for the designed bracket slot dimensions. The consequence of this incompletely filled bracket lu-men is torsional play that decreases engagement of the contact between the arch wire and the bracket.14 While decreasing friction, a potential benefit during early levelling, aligning, and sliding mechanics, tor-sional play reduces control of axial inclination and rotations necessary for ideal esthetics. In clinical


49


In the “Active Early” approach the vertical position of the upper anteriors are adjusted to meet esthetic need.15 (Figure 7) Smile arc bracket brackets; result in a bracket position apical to FA in most cases.

• The occlusal plane and the wire plane are not ne-cessarily parallel in patients with esthetic occlusions. In patients with “flat” occlusal planes or those re-quiring 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 bicuspids15. One of the most common esthetic problems during treatment is “flattening” of the smile arc associated with upper incisor intrusion to reduce overbite or transverse arch expansion without compensation of bracket position for smile arc.

Arch width, is not determined by the bracket: It is well established that arch width is a function of the wire used, independent of the ligation method of the bra-cket.17 Of equal important to arch width is arch form.

practice then, incremental increases in arch wires size is NOT an effective means of controlling axial inclination when the slot isn’t filled15 (Figure 5).

• Reliance on the appliance to produce esthetically superior results is impractical. Esthetic treatment goals targets upper incisor position in 3 planes of space are based on esthetics,16,5 so that reliance on “treatment built” into the appliance through slot angulation to the occlusal plane does not ensure est-hetically superior results. (Figure 6). The challenge of attaining optimal axial inclination of the upper incisor is the greatest challenge in treating non-extraction cases with crowding or pre-existing proclination. This is why we “flip and flock” H4 anterior brackets when needed.15

• Placing the bracket slot at the center of the anatomi-cal crown is not a requisite for excellent occlusions. Failure to adjust bracket position to meet esthetic need can result in esthetic decline in many patients.

Abb. 5

With familiar wire progressions and bracket slot positioned as suggested in „Straight Wire“ theory, torsion is unlikely to be developed within the slot

Abb. 6

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

Abb. 7

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

Abb. 8

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


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Arch forms that are too flat anteriorly, too broad through the cuspid and first bicuspid, and too narrow through the second bicuspid and molars make attaining a “12 tooth” smile difficult.15 The common practice of using unadjusted arch blanks does not provide arch forms that optimize esthetics.

Reducing challenges of appliance manufacturing and common clinical practices

To improve the appliance Ortho Classic has introdu-ced meaningful innovations that make an impact on the Orthodontist’s ability to both control and to predict how the appliance will respond. Where commonly used PSL brackets have manufacturing inconsistencies that become clinically significant,18 OC has manufacturing tolerances that are much tighter for more predictab-le performance. Secondly, we have reduced the slot depth to .026, resulting in two benefits: improving ro-tational control, and reducing the engagement angle for torsional control early in the treatment cycle, when using familiar wire progressions when the bracket is upright (Figure 9).

I want to initiate wanted forces and moments within the appliance as early in treatment as possible. The SAP18 bracket position adjusts the vertical position of the incisors, groups of brackets are inverted (“flipped and flocked”) to activate torsion in the appliance soo-ner, arch wire progressions and profiles are chosen that control axial inclination earlier in treatment, using arch forms that develop the posterior segments of the arches sooner, “ELSE” (Early Light Short Elastics) are employed to control forces and moments, and approp-

riate disarticulation adopted to encourage early “wan-ted” tooth movements. This has become known as an “Active Early” approach to case management.

An “Active Early” Approach

Traditional straight wire application relies on incre-mental 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 theory. One of the distinguishing features of the “Active Early” approach is adapting to “slop” that is present in all straight wires appliances. 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:

• Optimize “White and Pink” tissue contour prior to bonding: Patients today want beautiful faces, beauti-ful smiles, and beautiful teeth; meaning teeth and tis-sues need to be “optimized” for shape and contour. Prior to bonding, hard tissue recontouring improves the ability to place brackets in the appropriate loca-tion to maximize the smile arc, optimize axial inclina-tion, 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 pie-ce. Soft tissue revision using diode lasers are very useful in optimizing bracket position for smile arch enhancement (Figure 10).

Abb. 9

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..

Abb. 10

Positive effects of „White and Pink“ tissue optimization prior to bonding


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• Patient Specific SAP Bracket positioning: Bracket position is individualized to meet patient esthetic need. In patients “flat” occlusal planes or those that require increased enamel display, the divergence of the upper wire plane of the wire plane, created by bracket position, must increase anteriorly to develop the smile arc by extruding the upper incisors relative to the upper bicuspids. In patients with normal oc-clusal 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 divergence 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 progres-sions 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 world.19,20

• Torque Selection: With the worldwide tendency to treat more cases without extractions, the control of proclination of the upper anterior teeth has be-come 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 proble-matic. The challenge for many non-extraction cases has been in getting enough lingual crown torsion without having to resort to complex wire bending to torquing springs to attain esthetic results. 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 perfect is this regard, predictable when upright, and appropriate when flipped pro-viding 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 tor-sion is developed within the slot during commonly used arch wire progressions, and “flipping brackets, ensures that torsion is present in the slot from the outset of dimensional wires.

• ELSE (Elastics, Light, Short and Early) and Disarticu-lation: I have advocated use of early light elastics for the past 20 years, especially when using PSL me-chanics. Sabrina Huang, 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 treat-ment dramatically by maximizing “wanted” tooth mo-vements in all dimensions, and minimizing or mitiga-ting “unwanted” tooth movements early during the tipping or early torsional phases of treatment (Figure 13,14). Patient cooperation is critical, and reinforcing early progress through “every appointment” photo-graphy is very useful.

• Arch Width and Arch form: Through ”Active Early” case management practices, improved H4 applian-ces, and better arch forms we can now negate the adverse effects of “slop”. It has never made sense

Abb. 11

Effect of „flipping“ an anterior bracket is to place an effective degree of lingual crown torsion in the appliance

Abb. 12


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to me to start with arch wire forms that are narrower than the case needs to finish esthetically. Working with Ortho Classic, we have created a full suite of arch wires that develop the arches transversely from the outset to an esthetically pleasing arch form (Pitts

Standard, Pitts Broad) (Figure 15), where research has shown that a great amounts of transverse deve-lopment occurs.21 In order to help early torque con-trol, i2, i3 Leashes - 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 bra-ckets have not been “flipped” (Figure 16).

Abb. 13

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

Abb. 14

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

Abb. 15

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

Abb. 16

i2 Leash for torsional control early in treatment - Courtesy of Nimet Guiga 2015

Abb. 17

Initial Records - Courtesy Duncan Brown 2015

Abb. 18

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


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Summary and Case Management Considerations

By combining the SAP bracket position to adjust verti-cal position of the incisors, selecting arch wire progres-sions that control axial inclination early in treatment, using arch forms that develop the posterior segments of the arches sooner, and relying on ELSE and disarticu-lation to encourage “wanted” tooth movements, great things are possible. The decision to “flip” anterior bra-

ckets as a part of the “Active Early” approach, in combi-nation with the precision and dependable Rx of the H4 appliance makes a quantum leap for our treatment in the areas that Orthodontists have traditionally strugg-led with most in the PSL appliance (Figures 17-23).

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 befo-re. Our work in improving the lives of our patients, and the ease with which Orthodontist can deliver estheti-cally superior results efficiently is just beginning. With Ortho Classic, we are continuing to refine the appli-ance, as the “Active Early” protocols continue to evolve. I hope that this article will have provoked some thought and provided some insights to simplify your treatment and improve your results. Until next tim…

Abb. 19

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

Abb. 20

Very nice esthetic change efficiently attained- Courtesy Duncan Brown 2015

Abb. 21

Optimized upper incisor position- Courtesy Duncan Brown 2015

Abb. 22

Uprighted upper incisor with „Active Early“ protocols- Courtesy Duncan Brown 2015

Abb. 23

Post treatment CBCT confirming presence of buccal plate - Cour-tesy Duncan Brown 2015


54 D-88161 LindenbergTel. + 49 8381 89095-0E-Mail: [email protected]: www.w-c-o.de

D-28790 SchwanewedeTel.: +49 421 6588597Mobil: +49 173 2849579E-Mail: [email protected]

Ein neuer Standard bei gleichzeitig bekannter Technologie? Präzise!

Gewohntes Arbeiten für Ihr TeamDas Ihnen vertraute Design der aktuellen Standardtechnologie garantiert schnellste und problemlose Einarbeitung in das neue H4 BracketSystem. Auch die gewohnten Behandlungs-protokolle und -mechaniken kommen weiterhin zum Einsatz.

Mehr Präzision und optimiertes FinishingMit Toleranzen von +/- .001“ besitzt das neue H4 Bracket präzisere Slots als der Wettbewerb. Resultat: erstklassige Torque- und Rotationskontrolle sowie ein effektives Finishing.

Höchste Qualität bei niedrigen KostenMit dem patentierten H4 BracketSystem „Made in USA“ stehen Ihnen – und Ihren Patienten – kostengünstige und gleichzeitig qualitativ hochwertige Brackets zur Verfügung.

▲ Präzision ▼ Kosten ▲ Qualität

Das H4 System – ein passiv selbstligierendes BracketSystem – ist die revolutionäre Weiterentwicklung der aktuellen Standardtech-nologie. Ihre Patienten genießen mit dem H4 System einen äußerst guten Tragekomfort zu einem hervorragenden Preis-Leistungs-Verhältnis. Und Sie setzen auf ein System, das neue Vorteile bei bekanntem Handling bringt.

State-of-the-Art-Tech-nologie. Das passiv selbstligierende H4 BracketSystem bietet voll integrierte Haken, erhöhte Rotationskont-rolle mit .026 Slot und großzügige Flügel-Unterschnitte.

Mehr Informationen: h4system.de

nologie. Das passiv selbstligierende H4 BracketSystem bietet voll integrierte Haken, erhöhte Rotationskont-rolle mit .026 Slot und großzügige Flügel-Unterschnitte.

H4 Metall Bracket

H4 Go Ästhetik Bracket


Literatur

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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 generati-

on, Am J Orthod Dentofacial Orthop. 1993 104(1): 8 to 20

4. Dalstra,M. Actual versus theoretical torsional play in con-

ventional 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 com-

parison of oral bacteria and detection with adenosine

triphosphate-driven biuminescencse, Am J Orthod Den-

taofacial Orthop 2009; 135:426.e1 - 426.e9

6. Folco, A -Gingival Response in Orthodontic Patients;

Comparison study between Self Ligating and Conven-

tional 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, Univer-

sity of Alberta Phd Thesis, fall 2009

9. Major, T - Orthodontic Bracket Manufacturing Tolerances

and Dimensional Differences between Select Self Liga-

ting Brackets, Journal of Dental Biomechanics, 2010, Ar-

ticle ID 781321

10. Melenka,G - Three-dimensional deformation of ortho-

dontic 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 func-

tion of edge bevel on orthodontic wires; Am H Orthod

184 Jul;86(1); 43-51

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systematic review: Am J Orthod Dentofacial Orthop 2008

May; 133(5): 721-728

14. Meling, T - On mechanical properties of square and rec-

tangular stainless steel wires tested in torsion: Am J Den-

tofacial 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 ante-

rior posterior position on smiling esthetics: Angle Orthod

2011; 81: 121-129

17. Fleming, P - Comparison of maxillary arch dimensional

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randomized control trial: Am J Orthod Dentofacial Orthop

2013; 144: 185-193

18. Thorstenson G - Comparison of resistance to sliding bet-

ween 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 Beau-

ty, EJCO 2014;2:39-46

20. Guiga, N - Soft Tissue Diagnosis and SAP Bracket Positi-

oning, The Protocol 2015 V3: 22-31

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changes in fixed orthodontic appliances: Date from mul-

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Abb. Autor: Dr. Tom Pitts, Reno,NV (USA) B.A. University of Nevada, Reno 1958-61; D.D.S. from the University of Pacific, Valedictorian 1965; M.S.D. & Certificate of Orthodontics from the University of Washington, 1970; Orthodontics Reno, Nevada February 1970-present Anaheim, California 2009-2012; McMinnville,

Oregon 2015-present Developer of specific techniques to utilize self ligation 1988 - present; Associate Clinical Professor of Orthodontics University of Pacific 1998-present; Clinical Management & Practice Management Consultant – Pitts & Company, 1986-present; Clinical lectures globally with emphasis on orthodontic finishing and smile arc protection (in excess of 500)1988-present

Abb. Autor: Dr. Duncan Brown, Calgary, Alberta (Kanada); B.Sc. University of Toronto, graduated 1970; D.D.S. University of Toronto, graduated 1975; D. Ortho. University of Toronto, graduated 1978; Duncan Y Brown has practiced Orthodontics for 33 years, in Calgary, and for the last 15 years in Canmore; associate clinical professor at the University of Alberta, and served as guest

lecturer at University of Manitoba, University of British Columbia, and University of Western Ontario; consultant for P&G, Carestream Dental, G7H wires, and Ormco

D-88161 LindenbergTel. + 49 8381 89095-0E-Mail: [email protected]: www.w-c-o.de

D-28790 SchwanewedeTel.: +49 421 6588597Mobil: +49 173 2849579E-Mail: [email protected]

Ein neuer Standard bei gleichzeitig bekannter Technologie? Präzise!

Gewohntes Arbeiten für Ihr TeamDas Ihnen vertraute Design der aktuellen Standardtechnologie garantiert schnellste und problemlose Einarbeitung in das neue H4 BracketSystem. Auch die gewohnten Behandlungs-protokolle und -mechaniken kommen weiterhin zum Einsatz.

Mehr Präzision und optimiertes FinishingMit Toleranzen von +/- .001“ besitzt das neue H4 Bracket präzisere Slots als der Wettbewerb. Resultat: erstklassige Torque- und Rotationskontrolle sowie ein effektives Finishing.

Höchste Qualität bei niedrigen KostenMit dem patentierten H4 BracketSystem „Made in USA“ stehen Ihnen – und Ihren Patienten – kostengünstige und gleichzeitig qualitativ hochwertige Brackets zur Verfügung.

▲ Präzision ▼ Kosten ▲ Qualität

Das H4 System – ein passiv selbstligierendes BracketSystem – ist die revolutionäre Weiterentwicklung der aktuellen Standardtech-nologie. Ihre Patienten genießen mit dem H4 System einen äußerst guten Tragekomfort zu einem hervorragenden Preis-Leistungs-Verhältnis. Und Sie setzen auf ein System, das neue Vorteile bei bekanntem Handling bringt.

State-of-the-Art-Tech-nologie. Das passiv selbstligierende H4 BracketSystem bietet voll integrierte Haken, erhöhte Rotationskont-rolle mit .026 Slot und großzügige Flügel-Unterschnitte.

Mehr Informationen: h4system.de

nologie. Das passiv selbstligierende H4 BracketSystem bietet voll integrierte Haken, erhöhte Rotationskont-rolle mit .026 Slot und großzügige Flügel-Unterschnitte.

H4 Metall Bracket

H4 Go Ästhetik Bracket

Documents

FACHLICH Passive Self-Ligation 2014/WCO.pdf · No. 3-4 2015 (c) J ompr entof rthod rtho OO mf entof rthod ieferortho UOO) 47 Passiv Self-Ligation FACHLICH How ligation method fits