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Page 1: Methods of ligation

Methods of Ligation

Metal ligationBy Prof Dr

In orthodontics ligation method refers to themeans by which an archwire is held inside thebracket Conventionally elastic or metallic tieswere used to hold the archwire in place howevermore recently ligating methods have been designedand built directly into brackets

Currently the three most common ligation systems are active- and passive self ligation and conventional elastic ligation

Research has shown that different ligation types produce different force and moment systems along the orthodontic arch specifically passive self-ligation has been found to decrease the forces and moments produced when compared to elastic ligation which may lead to increased patient comfort

This is because elastic ligation actively holds

The wire in place against the bracket whereas passive ligation simply guides the wire while leaving room for movement

Variable Force Orthodontics Delta Force Bracket Features The Delta Force Bracket ndash A Change for the Better The Delta Force Bracket System incorporates an advanced design that allows you to control the friction between the archwire bracket and ligatures

The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results

Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces

Delta Force Ligation Options

Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment

Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control

Minimum Force Maximum Force

Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire

Minimum Force Maximum Force

Medium Force

Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation

Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 2: Methods of ligation

In orthodontics ligation method refers to themeans by which an archwire is held inside thebracket Conventionally elastic or metallic tieswere used to hold the archwire in place howevermore recently ligating methods have been designedand built directly into brackets

Currently the three most common ligation systems are active- and passive self ligation and conventional elastic ligation

Research has shown that different ligation types produce different force and moment systems along the orthodontic arch specifically passive self-ligation has been found to decrease the forces and moments produced when compared to elastic ligation which may lead to increased patient comfort

This is because elastic ligation actively holds

The wire in place against the bracket whereas passive ligation simply guides the wire while leaving room for movement

Variable Force Orthodontics Delta Force Bracket Features The Delta Force Bracket ndash A Change for the Better The Delta Force Bracket System incorporates an advanced design that allows you to control the friction between the archwire bracket and ligatures

The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results

Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces

Delta Force Ligation Options

Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment

Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control

Minimum Force Maximum Force

Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire

Minimum Force Maximum Force

Medium Force

Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation

Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 3: Methods of ligation

Currently the three most common ligation systems are active- and passive self ligation and conventional elastic ligation

Research has shown that different ligation types produce different force and moment systems along the orthodontic arch specifically passive self-ligation has been found to decrease the forces and moments produced when compared to elastic ligation which may lead to increased patient comfort

This is because elastic ligation actively holds

The wire in place against the bracket whereas passive ligation simply guides the wire while leaving room for movement

Variable Force Orthodontics Delta Force Bracket Features The Delta Force Bracket ndash A Change for the Better The Delta Force Bracket System incorporates an advanced design that allows you to control the friction between the archwire bracket and ligatures

The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results

Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces

Delta Force Ligation Options

Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment

Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control

Minimum Force Maximum Force

Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire

Minimum Force Maximum Force

Medium Force

Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation

Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 4: Methods of ligation

Research has shown that different ligation types produce different force and moment systems along the orthodontic arch specifically passive self-ligation has been found to decrease the forces and moments produced when compared to elastic ligation which may lead to increased patient comfort

This is because elastic ligation actively holds

The wire in place against the bracket whereas passive ligation simply guides the wire while leaving room for movement

Variable Force Orthodontics Delta Force Bracket Features The Delta Force Bracket ndash A Change for the Better The Delta Force Bracket System incorporates an advanced design that allows you to control the friction between the archwire bracket and ligatures

The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results

Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces

Delta Force Ligation Options

Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment

Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control

Minimum Force Maximum Force

Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire

Minimum Force Maximum Force

Medium Force

Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation

Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 5: Methods of ligation

This is because elastic ligation actively holds

The wire in place against the bracket whereas passive ligation simply guides the wire while leaving room for movement

Variable Force Orthodontics Delta Force Bracket Features The Delta Force Bracket ndash A Change for the Better The Delta Force Bracket System incorporates an advanced design that allows you to control the friction between the archwire bracket and ligatures

The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results

Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces

Delta Force Ligation Options

Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment

Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control

Minimum Force Maximum Force

Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire

Minimum Force Maximum Force

Medium Force

Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation

Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 6: Methods of ligation

Variable Force Orthodontics Delta Force Bracket Features The Delta Force Bracket ndash A Change for the Better The Delta Force Bracket System incorporates an advanced design that allows you to control the friction between the archwire bracket and ligatures

The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results

Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces

Delta Force Ligation Options

Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment

Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control

Minimum Force Maximum Force

Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire

Minimum Force Maximum Force

Medium Force

Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation

Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 7: Methods of ligation

The advanced technology and variations in ligature placement provide full control over the sliding mechanics offering the ability to easily increase or decrease friction for better treatment planning and results

Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces

Delta Force Ligation Options

Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment

Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control

Minimum Force Maximum Force

Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire

Minimum Force Maximum Force

Medium Force

Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation

Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 8: Methods of ligation

Delta Force Brackets have unique features to achieve variable force ligation throughout the treatment stages Early in treatment Light force can be attained for excellent sliding mechanics and low friction Intermediate stage of treatment Medium force can be utilized for anchorage and stabilization as well as initial torquing forces

Delta Force Ligation Options

Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment

Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control

Minimum Force Maximum Force

Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire

Minimum Force Maximum Force

Medium Force

Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation

Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 9: Methods of ligation

Delta Force Ligation Options

Minimum Force Start your treatment with passive ligation for minimum force Rapid leveling and aligning can be attained as the ligation is configured to prevent the ligature from directly contacting the archwire The free sliding mechanics created result in low friction and more patient comfort during this early phase of treatment

Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control

Minimum Force Maximum Force

Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire

Minimum Force Maximum Force

Medium Force

Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation

Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 10: Methods of ligation

Maximum Force You may finish your treatment with maximum force by locking the archwire in for full expression of the straight arch bracket Tie the ligature to lock the archwire in the tip torque and rotational control

Minimum Force Maximum Force

Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire

Minimum Force Maximum Force

Medium Force

Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation

Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 11: Methods of ligation

Medium Force In the next stage medium force is achieved through limited contact of the ligature and the archwire This configuration uses a standard ligation full tip torque and rotational control through lightly seating a rectangular archwire

Minimum Force Maximum Force

Medium Force

Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation

Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 12: Methods of ligation

Maximum + Force If needed for full expression of the straight arch bracket system you can apply maximum + force by placing an inverted V elastic ligation

Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 13: Methods of ligation

Optional Step ndash Rotation Control and Force If necessary extra rotation can be created by ligating behind one tie wing on one side Please note rotation will occur towards the non-ligated wing

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 14: Methods of ligation

Metal ligatureShort Twisted Preformed Ligature Ties Short Twisted Kobayashi Ligature Wires 008 PRE-FORMED SHORT

METAL LIGATURE TIES

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 15: Methods of ligation

The vast majority of fixed orthodontic appliances have stored

tooth-moving forces in archwires which are deformed within their

elastic limit For this force to be transmitted to a tooth wires need a

form of connection to the bracket

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 16: Methods of ligation

Elastomeric ligaturesrdquo and ldquoself-ligating bracketsrdquo are firmly

established orthodontic terms

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 17: Methods of ligation

Elastomeric modules are adversely affected by oral

environment demonstrates stress relaxation with time and exhibit great individual variation in properties

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 18: Methods of ligation

The normal force exerted by the ligature

has been estimated to be between 50 to

300 g

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 19: Methods of ligation

Bazakidou showed that there was no significant

differences between frictional resistance offered

by the conventional tied stainless steel ligature

and elastomeric module

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 20: Methods of ligation

Frictional forces can be reduced by

stretching the elastomeric modules prior

to placement on the brackets or by tying

stainless steel ligatures loosely around

the brackets

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 21: Methods of ligation

On the other hand stainless steel ligatures

can be too tight or too loose depending

upon the technique and needs of the clinician

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 22: Methods of ligation

Stainless Steel Ligatures

When stainless steel became available this was universally

adopted as the method of ligation Stainless steel ligatures

have several beneficial inherent qualities They are cheap

robust and essentially free from deformation and

degradation and to an extent they can be applied tightly or

loosely to the arch wire

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 23: Methods of ligation

Stainless Steel Ligatures

They also permit ligation of the archwire at a distance from

the bracket This distant ligation is particularly useful if the

appliance tends to employ high forces from the archwires

because this high force prevents sensible full archwire

engagement with significantly irregular teeth

Kobayashi Ties

Add an auxiliary hook to any bracket

Available in 010 012 or 014

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 24: Methods of ligation

Composite ligaturebull Fabricated from the acrylic monomer n-

butyl methacrylate and drawn poly

ethylene fibers

bull Due to stress relaxation properties

within an hour it loss 98 of ligation

forces( not used in sliding mechanism)

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 25: Methods of ligation

Specially formulated almond color coating

will not peel For use with ceramic or

plastic brackets

Teflon coated Ligature bull No discoloration

bull The coating wears off after 2-3 weeks and the metal is

exposed

bull Produces less friction when compared with elastomeric

ligatures amp stainless steel ligatures

bull It generates lighter forces of engagement of the arch

wire into bracket slot

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 26: Methods of ligation

Ligation materials bull 0010rdquo stainless steel ligature wire (G amp H wire Company) bull 0010rdquo Teflon coated stainless steel ligatures (G amp H wire Company) bull 012rdquo elastomeric ligature ties (American Orthodontics)

Effects of Different Ligature Materials on Friction in Sliding Mechanics Aparna Khamatkar1 Sushma Sonawane2 Sameer Narkhade3 Nitin Gadhiya2 Abhijit Bagade1 Vivek Soni4 Asha Betigiri3

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 27: Methods of ligation

Teflon coated stainless steel ligatures produced the least friction amongst the materials tested in both dry and wet conditions and there was no significant effect on friction in this group caused due to lubrication

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 28: Methods of ligation

Artificial saliva produced increased friction in elastomeric modules but does not cause any significant difference in friction when stainless steel or Teflon coated stainless steel ligatures are used

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 29: Methods of ligation

COATED KOBAYASHI SHORT TWISTED LIGATURE TIE HOOKS

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 30: Methods of ligation

Despite these good qualities and their widespread use over

many decades wire ligatures have substantial drawbacks

and the most immediately apparent of these are the length

of time required to place and remove the ligatures

Preformed Ligature Ties

bullPreformed in dead soft temper

bullAvailable in long or prendashcut

Stainless Steel Ligatures

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 31: Methods of ligation

One typical study found that an additional 11 minutes was

required to remove and replace two archwires if wire

ligatures were used rather than elastomeric ligatures

Bulk Ligature Spools

bull1 pound spools

bullBright finish with soft temper for

ease of use

Stainless Steel Ligatures

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 32: Methods of ligation

Stainless Steel Ligatures

Additional potential hazards include those

arising from puncture wounds from the ligature

ends and trauma to the patientsrsquo mucosa if the

ligature end becomes displaced

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 33: Methods of ligation

The use of stainless steel ligature ties has been shown to

increase friction through a dual mechanism There is a

higher engagement force between the archwire and bracket

and additional friction is generated by the contact of the

ligature surface with the archwire however elastomeric

ligatures can induce the same effects

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 34: Methods of ligation

A practical conclusion from these studies

was that self- ligating brackets showed

less frictional forces while the figure-of-

eight ligature configuration increased

friction significantly

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 35: Methods of ligation

Conventional brackets received metallic ligatures used to tie

the arch to the slots (A) always carefully bending them

perpendicular to the leveling arch (B) in order to reduce

plaque retention

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 36: Methods of ligation

Comparative Thickness of MPA

A Multi-Purpose Attachment -MPA can be used in different conditions The

thickness of an MPA is very less as compared to the conventional brackets

and tubes It has a body that is very thin - 04 mm and a lumen through

which a ligature wire or an 0016 arch wire can pass Curved MPAs are for

the canines premolars and molars and the flat ones are for the incisors

Multi-Purpose Attachment

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 37: Methods of ligation

EYELET

DIRECT BOND

Easily bonded to any tooth Specially designed base provides

a firmer bonding strength 10 per package

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 38: Methods of ligation

Stainless Steel Ligatures

Single Tie

One end of a small piece of ligature wire is passed through the

lumen of the attachment It is then passed under the arch wire on

the other side twisted around the other end cut and tucked in

This tie can be given for aligning and leveling a tooth

Methods of Ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 39: Methods of ligation

Stainless Steel LigaturesDouble Tie

One end of a small piece of ligature wire is passed through the lumen of the

attachment It is taken labial to the arch wire on the other side and reinserted

into the lumen from the same side After pulling out completely to the side

from where it was inserted earlier it is twisted around the other end of the

ligature wire cut and tucked in This tie can be given to correct rotation and to

upright a tooth

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 40: Methods of ligation

Crowding amp RotationsWhen the crown of a tooth is not exposed enough to place a bracket an MPA can

be bonded initially Once crowding is relieved a bracket can be bonded after

debonding the MPA

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 41: Methods of ligation

Cross bite Deep Bite and Scissors biteCorrection of cross bite of one or more teeth with brackets would require a bite

plate to disocclude the teeth in cross bite or else the brackets may debond or

the patient would be uncomfortable In such a case an MPA can be bonded as

incisal as possible on to a tooth in cross bite and the main arch wire can be tied

to the attachment to get the tooth into alignment

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 42: Methods of ligation

If the deep bite is more than 3 to 4 mm then a posterior bite

plate may be necessary until the tooth in cross bite crosses

over the opposing tooth Many a times it is difficult to bond

brackets on to the lower incisors in deep bite cases Deep bite

may be of a single tooth or of multiple teeth

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 43: Methods of ligation

Occlusal interference with even one tooth would be

uncomfortable and painful to the patient or it would

cause bond failure resulting in extended treatment

duration Teeth in scissors bite can also be corrected

with this attachment

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 44: Methods of ligation

Small clinical crownsAn MPA can be bonded onto the occlusal surface of a

tooth with a small clinical crown and brought into

alignment

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 45: Methods of ligation

A hook can be made by twisting the strands of a piece of

ligature wire after passing it through the lumen of the

attachment Even if the tooth gets covered by gingiva after

some time the hook remains out and can be used for tying

ligatures or elastomerics to the main arch wire to get the

tooth in occlusion and alignment

Impacted Teeth

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 46: Methods of ligation

As the tooth erupts the hook can be shortened

by cutting and bending it

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 47: Methods of ligation

Uprighting Second Molars

An impacted lower second or third molar can be

corrected by bonding an MPA and giving a spring which

distalizes and uprights the molar

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 48: Methods of ligation

It is acknowledged that metallic

ligatures produce around 30 to

50 of friction caused by

elastomeric ligatures

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 49: Methods of ligation

Little Effort Big Results by Andrew Hayes DDS

The everyday task of handling extraction spaces is an art in its

own right with an endless list of variables that require

clarification

Do you extract before or after bracketing

bullCanine retraction or en-masse retraction

bullMaximum or minimum anchorage

bullReciprocal space closure

bullLeveling and aligning before any space closure for sliding

bullActive or passive brackets in the buccal segments

bullSkeletal anchorage

bullPeriodontally or osteogenically accelerated orthodontics

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 50: Methods of ligation

The terms laceback and tieback have been commonplace in

the field of orthodontics for some time and are often

substituted for each other when theyre actually different

entities

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 51: Methods of ligation

Laceback was popularized by McLaughlin and Bennett in

the late 1980s 1 They described lacebacks as using 010

stainless steel ligature wires extending from the most

distally banded molar to the canine bracket

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 52: Methods of ligation

Lacebacks are generally placed on the brackets before

the insertion and ligation of the archwire The purpose

is to restrict canine crowns from tipping forward

during leveling and aligningmdasha tipping caused by the

addition of angulation in todays prescription brackets

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 53: Methods of ligation

Tieback refers to the use of stainless steel ligatures threaded

through an elastic module that goes directly from the terminal

molar to the canine bracket Unlike the laceback this type of

ligation is done after the placement and ligation of the archwire and

is commonly used for active space closure

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 54: Methods of ligation

Clinical trials have shown both active tieback and active laceback

methods to be reliable in anterior retraction3 4The active tieback

method using an elastomeric module has shown to have a clinically

significant decrease in space-closure time compared with the

laceback method with no elastic module Elastic modules when

prestretched to twice their original size have been shown to deliver

50-150g of force initially2

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 55: Methods of ligation

Canine retraction with active tiebacks is often rapid and has

minimal unwanted side effects even when using with light initial

nickel titanium archwires It is important to note that there is no

mesial-outdistal-in rotation evident on the canines that typically

seen with elastic chain or coil-spring retraction

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 56: Methods of ligation

It has been shown that the canines rotate 268 degrees

on average with laceback tie compared with 775

degrees with coil springs4 One study suggests that

using the tieback method of space closure has more

appropriate initial force than elastomeric chain5

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 57: Methods of ligation

Regional acceleratory phenomenonIt has been noted by many clinicians using tiebacks or lacebacks

that when theyre placed its not uncommon to see entire

extraction spaces close up on their own and severe crowding to

align at an astounding rate

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 58: Methods of ligation

Clinical caseA 13-year-old male presented for treatment with slight

overbite and overjet and maxillary canines actively erupting

toward the buccal The posterior occlusion was Class I molar

left and full step Class III molar on the right side resulting

in a significant mandibular midline discrepancy

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 59: Methods of ligation

The patient had a straight facial profile good lip

competency and mild chin deviation to the left In spite of

the asymmetric Class III dentition the resulting chin

deviation was mild enough to be considered within normal

limits

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 60: Methods of ligation

Mandibular mid line is deviated to the left

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 61: Methods of ligation

Cephalometric analysis revealed a strong Class III

component with severe dental compensation At 73 degrees

the lower incisors were retroclined approximately 20 degrees

from the norm Although ANB was only slightly negative the

Wits appraisal came out to -93mm Because of the severity of

the Class III skeletal component and the patient being in

active growth the likelihood of future surgery was discussed

before any treatment

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 62: Methods of ligation

bullTreatment planBegin with maxillary arch only

bullBond to create space for maxillary canine teeth

bullImprove overbite and overjet

bullWhen maxillary teeth aligned bond sectional wire to

Class III side

bullPlace active tieback from 30-27

bullExtract tooth 28

bullBond lower arch only when 27 is in Class I position

bullRe-evaluate for lower arch miniscrews in external oblique

ridge if necessary for retraction

bullClass III elastics prn

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 63: Methods of ligation

Treatment sequencingThe patients maxillary arch was bonded to include all teeth except

unerupted canines After three months adequate space was created

to bond the erupted canines After six months of maxillary-only

appliances no significant mandibular growth had taken place

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 64: Methods of ligation

Because of this bonding a lower sectional appliance

from molar to canine on the Class III side was done A

0014 NiTi wire was used and an active tieback placed

before dental extraction

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 65: Methods of ligation

This complex asymmetric Class III case has treated out quite well

and efficiently The use of the active tieback to close the extraction

space provided all the anchorage necessary in this maximum

anchorage situation Why arent all complex orthodontic cases

requiring extraction being treated this way and completed in 15-18

months After all its extremely simple to do the molars are great

anchorage and best of all the RAP is free turbocharging for space

closure

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 66: Methods of ligation

The majority of articles discussing retraction with tiebacks or lacebacks

typically conclude that the canine retraction is adequate but there is

significant posterior anchorage loss associated A recent meta-analysis

concluded There is no evidence to support the use of lacebacks for the

control of the sagittal position of the incisors during initial orthodontic

alignment Another recent article concluded Active laceback produced

anchorage loss of maxillary first molars3

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 67: Methods of ligation

It has been shown that teeth move faster in

proximity to a recent extraction compared with a

healed extraction site

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 68: Methods of ligation

If one follows the MBT philosophy step by step McLaughlin proposes a waiting

period for space closure with passive tiebacks or lacebacks until true passive

insertion of a 19x25 stainless steel archwire can be achieved for the sake of improving

sliding mechanics Without a protocol for having the tieback in place before or

immediately after extraction one may be missing out on a great deal of Mother

Natures own tooth-moving accelerator the RAP In fact the increase in cellular

activity is so great that Frost documented that RAP can expedite hard- and soft-

tissue healing stages between two and 10 times that of normal physiological activity

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 69: Methods of ligation

A 2013 study stated that extractions can be a good source for inflammatory

markers (These markers play an important role in osteoclast recruitment)

Because of this the group proposed that when possible extractions should be

delayed until the time of major tooth movement16

What if our patients are getting the extractions before initiating orthodontics

or if theyre in orthodontic treatment and have the extractions performed but

dont see us for six weeks What if were waiting for our large-diameter wire to

become completely passive Orthodontic literature has shown that extraction

undoubtedly leads to decreased bone density in the extraction17 18 Could we be

missing out on the wonderful advantages that biology has to offer

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 70: Methods of ligation

Figure 8 ligation to maintain

diastema closure

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 71: Methods of ligation

bullFinishing and detailing which is the last stage in treatment it is important to maintain closure of all spaces

bullPassive wire tie backs when rect wires in place Lacebacks ndash molar ndash cuspids ndash when light wires used

bullIn extn cases ndash figure of 8 liagature ties ndashacross extn site ndash to keep it closed

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 72: Methods of ligation

Serpentine wires- 1 week before appliance removal UampL arch

wires are removed ligated together in a serpentine fashion from PM

to PM with std ligature wire--- occlusion to settle without any

interdental spacingndash (in minimal discrepancies of tooth position)

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 73: Methods of ligation

Initial archwireAs in nonextraction cases in extraction treatment the initial maxillary archwire is usually a

0016-inch nickel-titanium wire Because extraction patients often exhibit more initial

crowding in the maxillary arch than do nonextraction patients this flexible wire is often

used for one to two additional appointments This archwire will correct the crowding

reduce the rotations and help level the teeth Because the point of least resistance is toward

the extraction site there is little flaring of the incisors as they align Most of the tooth

movement is into the extraction sites To make this even more effective the special low-

friction ligation can be placed on those teeth that need the greatest amount of movement

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 74: Methods of ligation

Modified laceback for canine retraction

The ligature wire is placed without the placement

of the arch wire

The arch wire is then placed with the open coil spring

and the canine bracket is ligated with metal ligatures

The ends of the ligatures are brought

forward and tied with the compression of

the open coil spring

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 75: Methods of ligation

Retraction of upper incisors

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 76: Methods of ligation

Class I malocclusion with severe double

protrusion treated with first premolars

extraction

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 77: Methods of ligation

En-masse retraction of anterior teeth

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 78: Methods of ligation

Effect of force applied to the orthodontic archwire

during sliding mechanics associated with mini-

implants

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 79: Methods of ligation

In cases with reduced or normal overbite the orthodontic

treatment should be initiated with individual retraction of the

canines and application of horizontal forces without any

vertical force components which are not helpful in these

patients

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125

Page 80: Methods of ligation

References

1- Seru Surbhi etal Effect of Ligation Method on Maxillary Arch ForceMoment Systems for a Simulated Lingual Incisor MalalignmentOpen Biomed Eng J 2014 8 106ndash1132-Delta force bracket system Ortho Organizers Inc All rights reserved PN 999-168 Rev 02113-Friction in orthodontic Dental lectures in all subjects for dental students Indian dental academy4-AV Arun etal Frictional characteristics of the newer orthodontic elastomeric

ligatures Indian J Dent Res 20112295-9

5-Aparna Khamatkar etal Effects of Different Ligature Materials on Friction in Sliding Mechanics J Int Oral Health 2015 May 7(5) 34ndash406-Vito Crincoli etal Friction Forces during Sliding of Various Brackets for MalalignedTeeth An In Vitro Study ScientificWorldJournal 2013 2013 8714237-A Pravindevaprasad and Beena Agnes Therese Tooth positioners and their effects on treatment outcome J Nat Sci Biol Med 2013 Jul-Dec 4(2) 298ndash3018-Gerson Luiz Ulema Ribeiro and Helder B Jacob Understanding the basis of space closure in Orthodontics for a more efficient orthodontic treatment Dental Press J Orthod 2016 Mar-Apr 21(2) 115ndash125


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