special article
From conventional to self-ligating bracket systems: Is it possible to
aggregate the experience with the former to the use of the latter?
Anderson Capistrano1, Aldir Cordeiro2, Danilo Furquim Siqueira3, Leopoldino Capelozza Filho3,
Mauricio de Almeida Cardoso3, Renata Rodrigues de Almeida-Pedrin3
DOI: http://dx.doi.org/10.1590/2176-9451.19.3.139-157.sar
Introduction: Orthodontics, just as any other science, has undergone advances in technology that aim at improving treatment
efficacy with a view to reducing treatment time, providing patients with comfort, and achieving the expected, yet hardly attained
long-term stability. The current advances in orthodontic technology seem to represent a period of transition between conventional brackets (with elastic ligatures) and self-ligating brackets systems. Scientific evidence does not always confirm the clear
clinical advantages of the self-ligating system, particularly with regard to reduced time required for alignment and leveling (a
relatively simple protocol), greater comfort for patients, and higher chances of performing treatment without extractions — even
though the number of extractions is more closely related to patient’s facial morphological pattern, regardless of the technique
of choice. Orthodontics has recently and brilliantly used bracket individualization in compensatory treatment with a view to
improving treatment efficacy with lower biological costs and reduced treatment time. Objective: This paper aims at presenting
a well-defined protocol employed to produce a better treatment performance during this period of technological transition. It
explores the advantages of each system, particularly with regards to reduced treatment time and increased compensatory tooth
movement in adult patients. It particularly addresses compensable Class III malocclusions, comparing the system of self-ligating
brackets, with which greater expansive and protrusive tooth movement (maxillary arch) is expected, with conventional brackets
Capelozza Prescription III, with which maintaining the original form of the arch (mandibular arch) with as little changes as possible is key to yield the desired results.
Keywords: Orthodontic brackets. Angle Class III malocclusion. Facial pattern.
Introdução: a Ortodontia passa, como toda ciência, por constantes evoluções tecnológicas que buscam aumentar a efetividade
da abordagem terapêutica, visando a diminuição do tempo de tratamento, o aumento do conforto para os pacientes, bem como
a obtenção da tão almejada, e pouco alcançada, estabilidade em longo prazo. O estágio atual de desenvolvimento tecnológico
da Ortodontia representa, ao que tudo indica, uma fase de transição entre os sistemas convencionais de ligação (com módulos
elásticos) e os chamados autoligáveis. As evidências científicas nem sempre consubstanciam a clara percepção clínica das vantagens desse sistema, no que diz respeito a um menor tempo de alinhamento e nivelamento, uma relativa simplificação técnica,
maior conforto para os pacientes, além do aumento da capacidade de tratamento sem extrações — embora essa indicação esteja
mais ligada à avaliação do padrão morfológico facial, e menos a qualquer escolha técnica. Desde um passado recente e não menos
brilhante, a Ortodontia vem utilizando a individualização de braquetes para tratamentos compensatórios, buscando aumentar
a efetividade da abordagem terapêutica, com menores custos biológicos e menor tempo de tratamento. Objetivo: o presente
artigo tem como objetivo apresentar um protocolo bem definido de melhor aproveitamento dessa fase de transição tecnológica,
buscando explorar o que cada sistema tem de melhor, principalmente sob a óptica da redução do tempo de tratamento e aumento
da capacidade de movimentação dentária compensatória em pacientes adultos. Especificamente, serão abordadas as más oclusões
de Classe III compensáveis, usando o sistema de braquetes autoligáveis onde se deseja maior capacidade de movimento expansivo
e protrusivo (arcada superior) e braquetes convencionais Prescrição III Capelozza® onde a manutenção da forma com mínima
mudança (arcada inferior) é imprescindível para a obtenção dos resultados almejados.
Palavras-chave: Braquetes ortodônticos. Má oclusão Classe III de Angle. Padrão facial.
» The authors report no commercial, proprietary or financial interest in the products or companies described in this article.
How to cite this article: Capistrano A, Cordeiro A, Siqueira DF, Capelozza
Filho L, Cardoso MA, Almeida-Pedrin RR. From conventional to self-ligating
bracket systems: Is it possible to aggregate the experience with the former to the
use of the latter? Dental Press J Orthod. 2014 May-June;19(3):139-57. DOI:
http://dx.doi.org/10.1590/2176-9451.19.3.139-157.sar
Submitted: March 20, 2014 - Revised and accepted: April 10, 2014
1
Professor of Occlusion and Orthodontics, School of Dentistry of Recife
(FOR—PE).
2
Masters student in Orthodontics, Sacred Heart University (USC).
3
Professor, Department of Orthodontics, Undergraduate and Postgraduate
Program, USC.
© 2014 Dental Press Journal of Orthodontics
» Patients displayed in this article previously approved the use of their facial and
intraoral photographs.
Contact address: Anderson Capistrano
Av. Engenheiro Domingos Ferreira, 3647, apto. 3101 - Boa Viagem
CEP: 51.020-035 – Recife/PE – Brazil — E-mail: capiss@uol.com.br
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special article
From conventional to self-ligating bracket systems: Is it possible to aggregate the experience with the former to the use of the latter?
INTRODUCTION
Patients with Class III facial pattern and severe
Angle Class III malocclusion pose difficulties for the
clinical management of sagittal relationship between
maxilla and mandible. Should surgery not be an option, clinical management is mainly concerned about
guiding the mechanics, since its onset, in order to
produce effects that meet the compensatory characteristics of the pattern. In the mandibular arch: restricted buccal tipping of incisors; maintenance of
reduced mesial angulation of anterior lower teeth
(except for canines that are usually distally angulated
and, now, will be uprighted); and, in the transversal
plane, respect to mandatory dentoalveolar compensatory mechanism — a sine qua non condition for transverse adjustment between the arches. As for the therapeutic management of the maxillary arch, it highly
welcomes transverse gains, increased mesial angulation of canines and controlled protrusion.
Analysis of Class III dental arches reveals that compensatory changes must be proportional to the degree
of malocclusion. As these patients nearly always undergo a functional routine, at least temporarily, the
exception will be if these compensatory changes do
not occur.1
The essence of compensatory treatment performed
with these patients is to adapt the concept of normality
for the occlusal relationship which is strongly influenced
by the degree of sagittal discrepancy between the arches.
In these cases, the therapeutic goals are completely individualized and treatment protocol must respect the
adapted concept of normality for the occlusal relationship. At compensatory treatment completion, maxillary
incisors will be more protruded and buccally tipped in
accordance with esthetic limitations; the maxillary arch
will be more expanded or with a decreased lingual inclination of posterior teeth; and all upper teeth will be
more mesially angulated. All these goals are set for the
maxillary arch with a view to increasing its circumference and length. Conversely, opposite goals are set for
the mandibular arch: mandibular incisors as well as posterior teeth more lingually tipped, with decreased mesial angulation for all other teeth.2
Orthodontics has continuously sought to improve
the efficiency of treatment in the attempt to reduce its
duration and chair time. Although average treatment
lasts between 1 and 2 years, there is an ongoing attempt
© 2014 Dental Press Journal of Orthodontics
to reduce it. To this end, several techniques and appliances — including surgical procedures, vibratory stimulation, greater use of individualized archwires and
brackets, as well as less frequent indications for tooth
extraction — will still be recommended. This article
explores three important aspects of such continuous
progression: bracket individualization, self-ligating
systems and mechanical customization used to achieve
greater therapeutic efficacy.3
WHEN TO TREAT?
Despite not being the primary objective of this article, it is worth noting that the compensatory approach
of skeletal Class III patients must safely begin, at least
theoretically, in patients whose mandibular growth
has ceased. Patient must present signs of skeletal maturity — for girls, 24 months after menarche; whereas
for boys, there must be signs of full pubescence, such
as voice alterations and facial hair. Such signs may be
confirmed by carpal radiograph which reveals that the
patient has achieved Haag &Taranger’s4 stage IJ — an
indication that compensatory orthodontic treatment
may begin or that there is a need for corrected treatment by means of orthognathic surgery. Unlike compensatory treatment of skeletal Class II malocclusions,
should orthodontic treatment be performed before the
patient achieves the stage of skeletal maturity, treatment stability is not guaranteed even if satisfactory occlusal correction is achieved.5
CHOOSING BRACKETS AND LIGATION
SYSTEMS IN EACH ONE OF THE DENTAL
ARCHES
In order to facilitate one’s understanding of the
treatment protocol presented in this article, it is important to divide the choice of brackets and ligation
system in accordance with each dental arch.
Maxillary arch
Over the last years, self-ligating brackets have
been given great emphasis, partially due to producing lower friction. The possibility of theoretically
applying force of appropriate magnitude increases
the chances of periodontal tissues producing a more
physiological response, thus producing more effective
dental movements and, as a result, decreasing side effects and reducing treatment time.6,7
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Increase in treatment efficacy is defined as the
achievement of results which are as good as or better
than those obtained by conventional treatment, especially within a shorter period of time. Additionally,
increased productivity brings along major benefits for
both clinician and patient. In orthodontic treatment,
these benefits include a reduced number of visits, reduced chair time, more comfortable treatment, clinical procedures that can be easily performed by the
orthodontist, a decreased need for extractions, less
invasive treatment procedures and minimized feelings of pain and anxiety for the patient. Additionally,
other factors associated with treatment conclusion
could also be included, namely: less decalcification
or root resorption or even better occlusal outcomes.
The major gains of self-ligating systems, which lay
the groundwork for approaches that opt for this type
of treatment, are as follows: safe and complete positioning of the arch into the slot of the self-ligating
bracket, which allows greater control of tooth movement; less resistance to sliding between the bracket
and the arch, which increases the expansive capacity
of the system; quicker arch removal and placement
with a consequent reduction in chair time.8
Transverse expansion produced by self-ligating
systems is explained by low friction between the
bracket and the leveling arch. This fact was demonstrated by a study conducted with 20 patients in
which the authors used non-conventional low friction elastometers. Their results revealed significant
transverse expansion during alignment and leveling
without further protrusion.9
On the other hand, another research assessed patients treated with passive, active and conventional
brackets and found no significant differences for the
distance between canines, premolars and molars. It is
worth noting that no statistically significant difference
was observed in the three groups assessed. Furthermore, in the group treated with passive self-ligating
brackets, the distance between canines as well as first
and second premolars had slightly higher values in
comparison to the other groups.10
A significant advantage of a good self-ligating system is its ability to produce higher friction in clinical situations that require movement of a tooth, or a
group of teeth, to be restricted along the leveling arch.
To this end, a conventional elastometer may be used.11
© 2014 Dental Press Journal of Orthodontics
The influence of therapeutic goals over the mechanical management of self-ligating systems is
strengthened by a convenient method that includes
the use of stops. They are little extensions of telescopic
tubes or U-shape 2 to 3-mm open hooks normally
positioned in the midline with the primary objective
of avoiding distal sliding of wire, which would invariably injure the patient. In the context of the treatment
protocol presented in this paper, it is recommended
that the stops be placed in the mesial surface of maxillary first molars with a view to favoring incisors protrusion and canine mesialization.12 The possibility of
fully exploring this capacity of producing expansion
and protrusion within a shorter period of time and in
a more effective and, perhaps, more biological manner is what explains our choice of using a self-ligating
system to treat the maxillary arch.
Mandibular arch
Individualized brackets were reintroduced and
spread in Brazilian literature by Capelozza Filho
et al.13 This type of bracket created an irrevocable
culture of customization in Orthodontics which aims
at fully respecting the morphology of patient’s original malocclusion and, as a result, setting individual
therapeutic goals. Capelozza® Prescription III brackets require considerably limited angulation (which
certainly is the most important factor for customization), with zero degree for canines and incisors and
increased lingual incisor torque (-6°). For this reason,
they are an excellent treatment option to maintain or
increase (in a controlled manner) the compensatory
features naturally present at the mandibular arch in
Class III. This set of brackets aims at minimizing protrusion and eliminating retroclination, which is key
to achieve success of compensatory treatment conducted with this type of patient. Nevertheless, customization is clearly not restricted to the choice of
brackets. It includes careful bonding, proper selection
of more restricted diagrams for the mandibular arch,
properly fitted wires and Class III elastic mechanics,
all of which decisively participate in preserving what
deserves to be kept and highlighting what should be
increased.2,5,13 Particularly with regards to diagram, it
seems important to consider that it is determined in
an objective manner, that is, respecting the essence of
the arch which, in Class III patients, tends to present
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given that this position favored qualitative analysis
and, as a result, improved prognosis for a compensatory treatment. For this reason, two analyses were
carried out in order to obtain patient’s facial morphological diagnosis: one in MI, and another in CR. Her
frontal facial analysis in MI revealed little asymmetry,
chin deviated to the right, severe anterior proclination, good zygomatic projection, compressive labial
seal and decreased lower third. Nevertheless, in CR,
analysis revealed that vertical shortening and facial
asymmetry were minimized, and a more balanced
face without signs of chin deviation (Figs 1A, 1B).
Profile analysis confirmed the aforementioned characteristics, both in MI and CR, as well as an increased chin-neck line in MI. Nasolabial angle was
closed partially due to the compensation of maxillary
incisors, but, especially in MI, due to forced labial
seal and consequent decreased ALFH (Figs 1C, 1D).
Smile analysis revealed good incisors exposure with
normal inclination and slight deviation of the occlusal
plane, which was later justified by unilateral crossbite
on the right side (Fig 1E).
Occlusal assessment in MI revealed a sagittal relationship between maxilla and mandible of ¾ of Class
III on the right side and ¼ on the left side, with anterior and posterior crossbite on the right side without
involving second molars. Mandibular incisors were
retroclined at a clearly compensatory position as a result of a decreased maxillomandibular step. Mid lines
coincided with the facial midline (Fig 1F, 1K).
A panamoramic radiograph confirmed the presence of all permanent teeth, with third molars in occlusion and a periodontal condition that was consistent with patient’s age. Tooth #14 had a provisional
crown as well as an intracanal post and presented favorable conditions for orthodontic treatment onset
(Fig 3A).
From a skeletal standpoint, morphological evaluation of the cephalogram revealed a negative maxillomandibular step with mild mandibular prognathism,
especially due to an anticlockwise mandibular rotation, given that the cephalogram was taken at maximal intercuspation. Although mandibular incisors
were lingually tipped and strongly compensated, they
were also well inserted into the symphysis. Conversely, maxillary incisors were well positioned in the
maxillary bone (Fig 3B).
an increase in the distance between canines and a decrease in the posterior width of the mandibular arch.16
According to the literature, mandibular canines
of Class III patients present an average difference in
angulation of approximately 5 degrees in a distal direction, in comparison to Class I patients. For this
reason, Class III patients tend to promote a natural
compensation of mandibular incisors. Conversely,
their maxillary canines present a smaller difference
in mesial angulation of 2 degrees. In short, Class III
patients have less tipped mandibular canines (-1.75 o)
in comparison to Class I patients (3.5o). These values are very close to those suggested for compensation brackets (Prescription III®): zero degree for
mandibular canines.14
There is a tendency towards lingual inclination of
mandibular incisors in cases of naturally compensated
Class III malocclusion, since incisors inclination
tends to promote a movement of opposite direction
and which is compensatory to the maladjustment that
results from a maxillomandibular skeletal imbalance.
In other words, Pattern III, Class III patients have
maxillary incisors more buccally tipped and mandibular incisors with increased lingual inclination.14
It is difficult to preserve the natural compensatory
characteristics of the mandibular arch with the use of
self-ligating brackets because, if we compare the degree of expansion achieved by self-ligating and conventional systems, it is clear that there is a stronger
tendency for the former to increase the width of the
arch.15 Therefore, since this effect does not agree with
treatment primary objective — which consists of preserving the transverse dimension of the mandibular
arch — the treatment protocol reported herein chose
to use the system of conventional brackets.
CASE REPORT 1
A 36-year and 9 month-old female, Caucasian
patient sought orthodontic treatment with a chief
complaint of anterior crossbite and mandibular prognathism. Her clinical examinations revealed a great
difference between maximal intercuspation (MI)
and centric relation (CR) in the anteroposterior and
vertical direction, with a major impact on face and
occlusion (Fig 1). With a view to performing a safe
morphological analysis, an acrylic interocclusal device
was manufactured (Fig 2) with the mandible in CR,
© 2014 Dental Press Journal of Orthodontics
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A
B
C
D
F
G
H
I
J
© 2014 Dental Press Journal of Orthodontics
special article
E
Figure 1 - Initial photographs: A) frontal facial
view in maximal intercuspation (MI); B) frontal
facial view in centric relation (CR); C) facial profile in MI; D) facial profile in CR; E) smiling; F)
intraoral frontal view in MI; G) intraoral frontal
view in CR; H) intraoral lateral right view in MI.
I) intraoral lateral left view in MI; J) intraoral occlusal maxillary view; K) intraoral occlusal mandibular view.
K
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From conventional to self-ligating bracket systems: Is it possible to aggregate the experience with the former to the use of the latter?
A
Figure 2 - Acrylic resin device used for occlusal
fixation in CR.
B
Figure 3 - Initial photographs: A) Panoramic radiograph; B) Profile radiograph.
Capelozza® Prescription III brackets (Abzil, 3M™)
have a very positive characteristic that favors the therapeutic goal recommended for this patient: maximum preservation of the mandibular arch or, in
small proportions, a modest increase in the natural
compensatory characteristics. Torque of -6o would be
applied to mandibular incisors to this end. In other
words, mandibular incisors would be severely lingually tipped by the mechanics to which brackets
would contribute. Although there was no intention
of further using rectangular wires in the mandibular
arch, this procedure does not break with the concept
of maintaining the original form of the arch. Without
a doubt, the key factor to achieve treatment success in
this compensatory game is the absolute economy of
angulations provided by brackets with no angulation
bonded from canine to canine, which results in little
protrusion and requires less space during leveling.
In this approach, which the orthodontist assumes
total control of treatment, bracket bonding was individualized and maxillary incisors were more cervically bonded so as to adjust the incisal curvature
of final smile and, at the same time, allow low reading of strong torque embedded in maxillary brackets. Before interpreting this as nonsense, one should
remember that, in this case, treatment approach intended to increase maxillary protrusion in accordance with esthetic limitations. Additionally, there
is speculation that this treatment protocol stimulates
greater bodily buccal movement. Should mandibular
incisors be bonded, they were more cervically positioned in relation to the vestibular axis point with
the height of previously leveled canines as reference.
After collecting all necessary occlusal, functional,
cephalometric and face-morphology examinations,
and evincing a deviation from CR to MI, we came
up with the following diagnosis: adult patient, mild
skeletal Class III, brachyfacial, borderline for Short
Face and with an acceptable facial pattern. Class III
relationship on the right side and ¼ on the left side,
with anterior and posterior crossbite on the right side.
Well-positioned maxillary incisors and retroclined
mandibular incisors in relation to the bone. Patient’s
morphological analysis of the face in CR (Figs 1B,
1D) reinforced the need for compensatory treatment
that aimed at increasing volume in the maxillary arch
and restricting the mandibular arch. The absence of
crowding in the mandibular arch favored such treatment goal, although it hindered an increase in circumference in the maxillary arch.
Treatment plan included the use of Damon MX®
standard self-ligating brackets (Ormco), with torque
of +12o applied to central incisors, +8o to lateral incisors and 0o to canines, respecting the need for increasing volume in the maxillary arch within esthetic
limits — which could be exceeded with the use of
high torque brackets (+17°, +12° and +6°, respectively) or by producing, by means of low torque brackets (+7° and +3°, for central and lateral incisors), a
weaker protrusion, insufficient to correct crossbite.
The mandibular arch received Capelozza® Prescription III brackets (Abzil, 3M™). At first, mandibular
incisors were not included in order to avoid protrusion (given that anterior lower crowding was quite
discrete) which could have been produced by initial
and random leveling of lower teeth (Fig 4).
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by producing an effect of occlusal unlocking.
Also, with a view to directing movement towards
the areas of interest, which were carefully investigated, stops were bonded to the mesial surface of
first molars and the arch was adjusted with a space
of 2 mm between the wire and the bracket. In other
words: The wire was mesially fitted on first molars
and passed 2 mm away from the maxillary incisors,
thereby stimulating protrusion of these teeth. Additionally, elastomers were placed on premolars and
canines so as to concentrate the expansion in the anterior region, thereby meeting the primary treatment
objective (Fig 5). After correcting anterior crossbite,
mechanics was directed towards teeth #14 and 15.
With a view to maintaining the compensatory
All aforementioned alterations are favorable in compensatory cases of skeletal and dental Class III, as
they favor good overbite as well as functional anterior
guidance.
With a view to enhancing the position of mandibular orthopedic stability and deconstructing maximal
intercuspation, fixed stops made of composite resin
were bonded to the lingual surface and incisal third
of mandibular incisors with balanced and uniform
occlusal contact with antagonist teeth (Fig 4E). This
measure favors buccal movement of teeth involved in
crossbite, stimulates extrusion of posterior teeth within the posterior interocclusal space created to produce
gain in vertical dimension of occlusion (VDO), and, at
the same time, improves treatment mechanical efficacy
A
D
A
© 2014 Dental Press Journal of Orthodontics
B
C
E
Figure 4 - Intraoral photographs at the beginning
of complete levelling in the maxillary arch and partial levelling in the mandibular arch.
B
Figure 5 - Photographs depicting right and left
maxillary quadrants, highlighting stops placement and the use of elastic ligatures.
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create greater demand for treatment of potential side effects. From this initial phase on, maxillary leveling was
conducted with a sequence of archwires evolving to
0.019 x 0.015-in steel wire. As for the mandibular arch,
the sequence of archwires stopped at 0.018 steel wires
because rectangular wires were not necessary for additional angulation or inclination reading. During the formatting phase of the mandibular arch, morphology was
consistent with the initial treatment goals. Moreover,
even if individualized brackets were used, they were not
completely customized and, for this reason, their maximum expression may not suit this type of patient (Fig
7). In the final treatment phase, panoramic and lateral
radiographs were taken with a view to assessing tooth
positioning and potential biological costs inherent to
orthodontic treatment (Fig 8).
Figure 9 shows slight, yet major improvements
in lip contact. It also depicts decreased asymmetry
initially shown at maximal intercuspation in frontal view. Figure 10 shows good occlusal relationship
achieved after removing the appliance.
Figure 11 shows initial and final cephalometric
tracings superimposition at treatment completion,
which allowed an accurate analysis of the mechanisms
that enabled occlusal adjustment. Improvements were
achieved due to a set of several small adjustments,
namely: correction of discrepancy between CR and
MI, retroclination of mandibular incisors and protrusion of maxillary incisors. All these factors added up
to magnify the positive impacts on patient’s occlusion
and face as well as to allow transverse expansion of the
maxillary arch and crossbite correction.
Treatment lasted for 15 months, with a total number of 10 visits since the appliance was firstly installed
in the maxillary arch until it was removed.
Figure 6 - C6A7 objective anatomic individual diagram.
characteristics, which are also related to the form
of the arch, C6A7 diagram was chosen (Fig 6) for
favoring slight retroclination of mandibular incisors
and protrusion of maxillary incisors. Additionally,
in the posterior region, it respected the mandatory dentoalveolar compensatory mechanism of the
mandibular arch.16
Two months after the onset of leveling in the maxillary arch, a mandibular appliance was installed with immediate use of Class III 5/16-in rubber bands supported
by hooks placed on maxillary first molars and mandibular canines. This measure immediately prevented
mandibular protrusion and, at the same time, produced
space gain necessary for future leveling of mandibular
incisors without stimulating buccal inclination.
Without a doubt, this treatment phase was the most
difficult in terms of mechanics, given that any careless
procedure could worsen anteroposterior relationship
between the maxilla and the mandible and, as a result,
A
B
C
Figure 7 - Intraoral photographs at the end of leveling in the maxillary arch (with 0.019 x 0.025-in wire) and in the mandibular arch (with 0.018” steel wire).
© 2014 Dental Press Journal of Orthodontics
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A
B
Figure 8 - Radiographs at treatment completion: A) Panoramic; B) Profile radiograph.
A
B
C
Figure 9 - Final extraoral photographs.
A
B
C
D
E
F
© 2014 Dental Press Journal of Orthodontics
Figure 10 - Final intraoral photographs.
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maxillary deficiency and differences between palatal
and mandibular planes. Maxillary incisors were buccally tipped as expected. However, mandibular incisors counteracted occlusal analysis as they were well
positioned in the symphysis (Fig 13B).
Diagnosis was as follows: adult patient, mild
skeletal Class III, dolichofacial with acceptable facial pattern, especially from frontal view. Class III
relationship on the right side, with anterior crossbite on tooth #12, decreased overbite and overjet,
agenesis of tooth #22 and increased buccal tipping
of maxillary incisors.
Patient’s self-perception of facial normality in
frontal view reinforced the need for compensatory
treatment while eliminating the need for absolute corrective treatment by means of orthognathic surgery
for maxillary advancement. In this context, treatment
plan was directed towards the protocol presented
herein: the use of Damon MX® (Ormco) self-ligating
brackets. Unlike case 1, high torque prescription
was chosen for the maxillary arch (CI +17o, IL +10o,
C +7o) as it required greater protrusion and expansion, both of which were justified by more expressive buccal torque applied to the maxillary arch and
Capelozza® Prescription III brackets (Abzil, 3M™)
used in the mandibular arch.
In case 2, the greatest challenge was to increase
overbite and overjet while opening spaces for appropriate rehabilitation of maxillary lateral incisors without
producing the effect of reversing the incisal curvature
at smiling — which is quite common in cases requiring major compesantion of maxillary incisors. In order
to control such effect, Prescription III brackets were
used in the mandibular arch with brackets more cervically bonded on maxillary lateral and central incisors.
Once again, with a view to directing movement
towards the areas of interest, stops were bonded to
the mesial surface of first molars, thereby producing
a space between the 0.14” heat-activated wire and
the bracket in the anterior region of the maxillary
arch. Additionally, elastic ligatures were used from
right and left premolars to right canine as — transversely speaking — those teeth functioned as reference of normality. Treatment onset on the maxillary arch was of paramount importance, and so was
installing the appliance on the mandibular arch 40
days after using 0.014 x 0.025-in heat-activated wire
Figure 11 - Initial (black) and final (red) cephalometric tracings superimposition.
CASE REPORT 2
A 26-year and 2-month-old female, Caucasian
patient sought orthodontic treatment with chief
complaint of lack of space for implant placement
at tooth #22 site and small-sized tooth #12. Her
profile analysis revealed maxillary deficiency and
unsatisfactory lip contact with her lower lip ahead
her upper lip and open nasolabial angle (Fig 24A).
Her frontal facial analysis revealed a balanced face
with good acceptability (Fig 12 B). Her smile was
characterized by lack of space, disproportional maxillary lateral teeth and tooth #21 darkened by endodontic treatment (Fig 12C).
Her occlusal analysis revealed Class III subdivision malocclusion of ¼ on the right side, crossbite on
tooth #12 as well as decreased overbite and overjet.
Her mandibular arch showed evident compensation,
with retroclined incisors and mandibullar canines
with no mesial angulation. Mid lines coincided with
the facial midline (Fig 12D, 12H).
Panamoramic radiograph confirmed maxillary and
mandibular third molars as well as tooth #22 agenesis
corrected by an adhesive prosthesis bonded to teeth
#21 and 23. She presented general periodontal condition that favored orthodontic treatment (Fig 13A).
From a skeletal standpoint, the cephalogram revealed a negative maxillomandibular step with mild
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A
B
C
D
E
F
G
H
Figure 12 - Initial extra and intraoral photographs.
A
B
Figure 13 - Initial radiographs: A) Panoramic radiograph; B) Profile radiograph.
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A
D
From conventional to self-ligating bracket systems: Is it possible to aggregate the experience with the former to the use of the latter?
B
C
E
Figure 14 - Initial treatment approach with leveling of maxillary arch performed with stops placed
on the mesial surface of molars, elastic ligatures
on anchorage teeth and the use of 0.014-in heatactivated with anterior slack.
in the maxillary arch — 4 months after treatment
onset. In other words, it was installed after the maxillary arch form was established, which used to be
limited, and was now more expanded and defined.
In order to favor greater anterior overbite, maxillary
second molars were not included in leveling. This
set of actions is definitively in accordance with the
therapeutic goals previously established for patient’s
compensatory treatment (Fig 14).
C4A7 diagram was chosen (Fig 15) for providing
greater freedom to improve the form of the mandibular arch, which was allowed by the great demand for
space in the maxillary arch.
The sequence of wires used in the maxillary
arch was as follows: 0.014” heat-activated; 0.014 x
0.025-in heat-activated; 0.017 x 0.025-in TMA;
0.019 x 0.025-in TMA and 0.019 x 0.025-in steel
wire. As for the mandibular arch, 0.014 NiTi superelastic and 0.016 NiTi superelastic wires were mesially fitted, followed by 0.018” steel wire installed
with omega loops.
Figure 16 shows the effect produced with the use
of open and closed springs to equalize the space necessary for proper rehabilitation of teeth #12 and #22.
Final panoramic and profile radiographs not only
certify safe and trustful results, but also confirm intraosseous space gain for future implant placement on
tooth #22 site (Fig 17).
Treatment produced considerable improvements
and discreet, yet extremely positive benefits for
the face. Thus, it proves the protocol adopted herein
© 2014 Dental Press Journal of Orthodontics
Figure 15 - C4A7 objective anatomic individual diagram.
to be efficient with regard to the therapeutic goals
previously established (Fig 18).
Cephalometric tracings superimposition helps
us understand that right choices were made with a
view to achieving functional and esthetic balance
of a malocclusion that presents compensatory characteristics inherent to both skeletal Class III and
sagittal relationship between maxilla and mandible
aggravated by agenesis in the anterior region of the
maxillary arch (Fig 19).
Treatment lasted for 18 months, with a total number of 11 visits.
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B
C
D
E
Figure 16 - Final leveling phase with open and
closed springs installed to increase in circumference in the region of teeth #12 and #22.
A
B
Figure 17 - Radiographs at treatment completion: A) Panoramic; B) Profile radiograph.
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A
B
C
D
E
F
G
H
Figure 18 - Final extra and intraoral photographs.
CASE REPORT 3
A 23-year-old male, Japanese-descendent patient
sought orthodontic treatment with chief complaint
of unilateral crossbite on the right side and mandibular shift to the right. His frontal analysis revealed
vertically balanced face with discreet laterognathism. His profile analysis revealed clearly balanced
maxillomandibular relationship with passive lip seal,
slightly open nasolabial angle, well-defined mentolabial sulcus and normal chin-neck line. At similing, the patient presented some alterations such as
reversed incisal curvature in relation to the lower
lip curve, asymmetry in the positioning of teeth #13
and 23, and increased lingual inclination of teeth
#14 and 15 (Figs 20A, B, C). His occlusal analysis
(Figs 20D to 20H) revealed bilateral Class III sagittal relationship more severe in the second premolar
Figure 19 - Initial (black) and final (red) cephalometric tracings superimposition.
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A
B
C
D
E
F
G
H
Figure 20 - Initial extra and intraoral photographs.
Unlike the aforementioned patients, this patient
was diagnosed as skeletal Class I with mild laterognathism to the right, dolichofacial and pleasant face. Bilateral Class III relationship with unilateral crossbite
on the right side and absence of overbite and overjet. He was asked about the possibility of undergoing
orthognathic surgery, since the procedure would be
the only one capable of correcting asymmetry — one
of his chief complaints. Nevertheless, given that mild
mandibular shift did not worsen after a year, the possibility of surgery was discarded and compensatory
treatment was chosen to solve patient’s occlusal problems, thereby enduring his small skeletal defect. Although the patient was skeletal Class I, the relationship between maxilla and mandible was Class III and
granted him occlusal characteristics of Class III. For
this reason, he was treated under the same protocol
employed in cases 1 and 2.
region than in the canine region. This difference in
magnitude may be explained by the level of compensation present in mandibular canines and premolars
that resigned their mesial angulations. Transverse
relationship was impaired by unilateral crossbite on
the right side and decreased overbite as well as overjet in the anterior region. Frontal intraoral view revealed a 2-mm deviation of the lower midline to the
right coinciding with mandibular skeletal deviation.
Panamoramic radiograph revealed periodontal
and structural health that favored orthodontic treatment. Third molars had been previously extracted
(Fig 21A). Morphological exams of the cephalogram
confirmed all aforementioned positive facial characteristics and revealed something new: vertical maxillary excess unable to negatively affect patient’s face or
smile. Maxillary and mandibular incisors were well
positioned into the jaws (Fig 21B).
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A
B
Figure 21 - Initial radiographs: A) Panoramic radiograph; B) Profile radiograph.
A
B
C
Figure 22 - A) Initial treatment approach with leveling of maxillary arch performed with stops placed on the mesial surface of molars, elastic ligatures on anchorage
teeth and the use of 0.014” heat-activated with anterior space between teeth #11 and #14.
Once again, we faced the need for controlled
maxillary protrusion and expansion as well as restriction of both in the mandibular arch. Figure 22 shows
similarities with the aforementioned protocol: treatment onset on the maxillary arch, use of stops and
elastic ligatures with a view to achieving protrusion
and expansion in the right anterior and lateral region.
C5A9 diagram (Fig 23) was chosen to preserve
the form of the mandibular arch, given that unilateral
crossbite on the right side, without deviation from MI
to CR, was a predictive factor of potential difficulties
in achieving proper transverse control — especially in
the case of an adult patient.
The sequence of wires used in the maxillary arch
was as follows: 0.014-in; 0.016-in; 0.014 x 0.025in; 0.018 x 0.025-in heat-activated; 0.019 x 0.025in TMA and 0.019 x 0.025-in steel wire. As for the
mandibular arch, the following arches were used:
0.014” NiTi superelastic wire mesially fitted; 0.016
and 0.018-in steel wires with omega loops. This
patient required compensatory bends (Fig 24) for a
more individualized treatment finishing, especially
due to laterognathism.
© 2014 Dental Press Journal of Orthodontics
Figure 23 - C5A9 objective anatomic individual diagram.
Final panoramic and lateral radiographs reveal absolute control (Fig 25). Figure 26 certifies protocol
efficacy. Patient’s face did not change, as expected.
Nevertheless, gains in overbite and overjet, correction of unilateral crossbite and Class I relationship established between canines provided him with a functional routine and expressive esthetic benefits.
Initial and final cephalometric tracings superimposition reveals that the effects described in case report 1 and 2 were repeated in case 3 (Fig 27).
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Figure 24 - Final leveling phase with individualized bends for treatment finishing: buccal steps on teeth #16, 26, 12 and 13; and “Z” bend on tooth #21.
A
B
Figure 25 - Radiographs at treatment completion: A) Panoramic radiograph, B) Cephalometric cephalogram.
A
B
C
D
E
F
G
H
Figure 26 - Final extra and intraoral photographs.
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system, since most of them aim at comparing the
magnitude of movement during alignment and leveling without considering the individual variations of
the samples.10,17 From this point of view, self-ligating
brackets would be just a more practical method employed to fit and remove archwires. Nevertheless, directing mechanics associated with bracket individualization towards flexile therapeutic goals seems to
enhance treatment outcomes. Carefully using stops
and elastic ligatures to manage friction in self-ligating bracket systems used in areas where movement
is less required is a good example of how to explore
the maximum productivity of this system, and justifies the methodology employed to treat the patients
reported herein.
Using individualized Capelozza® Prescription III
brackets (Abzil, 3M™) in the mandibular arch to
treat Class III is essential to yield more esthetically
tolerated results, given that maximum maintenance
of the arch form creates possibilities of moderate
gains in the maxillary arch without hindering smile
esthetics. This occurs because the ideal morphology
for sagittal correction of the arches is limited by smile
reading; thereby giving the orthodontist the opportunity to create a less protrusive and less expansive
maxillary arch than he would mechanically do.
It seems imperative to treat these malocclusions by
means of absolutely individualized methods, seeking
to preserve what should remain and strictly change
what must be corrected. Treatment that starts on a
reasonable or poor occlusal morphology should continuously evolve to improvements so as to prevent a
greater demand for treatment.
Figure 27 - Initial (black) and final (red) cephalometric tracings superimposition.
Treatment lasted for 24 months, with a total number of 17 visits. Treatment time was greater than expected due to unilateral crossbite, the need for individualization bends and the clinician’s learning curve
— since this was the first patient treated under the
protocol described herein.
FINAL CONSIDERATIONS
The gains in efficiency of alignment and leveling
produced by self-ligating brackets have not been scientifically proved. Some recent studies do not seem
favorable to confirm the greater productivity of this
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