fixed appliance by almuzian

university of glasgow

Fixed appliances

Personal notes

Dr. Mohammed Al-Muzian

1/1/2013

.

FIXED APPLIANCE

History

1. E arch appliance (Angle)

2. Pin and tube appliance (Angle)

3. Ribbon arch appliance (Angle)

4. Standard Edgewise appliance (Angle 1920`s)

5. Modified standard Edgewise appliance (using rotational arm or Lewis arm, using different

slot size)

6. Labiolingual twin wire appliances

7. Begg appliance (Begg 1950`s) he turn the ribbon arch upside down so it pointed

gingivally rather than occlusally, used stiff SS wire, intermaxillary elastic and use

auxiliaries and advocate extraction.

8. Pre-adjusted Edgewise appliance (Straight Wire – Andrews 1970`s)

9. Lingual appliance (Kurz 1970`s)

10. Tip Edge appliance (Kesling 1988)

Comparison of fixed and removable appliances

NB: Note that the headgear tube may be placed gingivally (closer to the centre of

resistance of the tooth) or occlusally (less gingival impingement and easier for patient to

see for fitting headgear

Mohammed Almuzian. University of Glasgow, 2013 Page 1

General classification of the FA

Andrews defines four basic appliance types:

1. Non-programmed appliances: A non-programmed appliance is a set of brackets that are

the same for all tooth types and which rely totally on wire bending to obtain optimal tooth

position.

2. Partially programmed appliances: Partially programmed appliances are sets of brackets

designed with some built-in features but which always require some wire bending. These

appliances by definition lack at least one slot-siting feature.

3. Fully programmed appliances: Fully programmed appliances are a set of brackets

designed to guide teeth directly to their goal positions with unbent archwires. The generic

term is pre-adjusted edgewise appliances.

4. Semi-custom appliances: The term semi-custom appliances is used to describe the

variations from standard Straight-Wire technique, such as inverting brackets or mixing of

brackets from different prescriptions in order to produce specific tooth movements to an

individual patient's needs.

5. Custom appliances: Custom appliances are a set of brackets designed to match precisely

the unique morphology and guidance needs of a specific patient eg. Insignia

Classification of bracket designs

Single wing

Siamese

Mini bracket

Self-ligation

Tip edge

The standard edgewise appliance

The standard edgewise appliance originated from the work of Edward Angle (Angle,

1928).

The standard edgewise appliance became the fixed appliance of choice up until the late

1970s

But it did suffer from several disadvantages.

1. In particular, the non-programmed bracket slot meant that final detailing of tooth position

in rectangular wires was dependent upon many bends being placed within the archwire for

each individual tooth


2. The presence of these bends also meant that space closure had to be carried out with

closing loops, which were also complicated to bend

3. In addition, teeth are moved bodily along the archwire through alveolar bone using an

edgewise appliance, which is demanding upon anchorage.

Light wire appliances (Begg appliance design)

1. In an effort to overcome the high anchorage demand associated with the standard

edgewise appliance, an Australian orthodontist, P. Raymond Begg developed a fixed

appliance system where tooth movement was based around the concept of differential

force (Begg, 1956):

• The tooth crowns are initially tipped into their desired position using intermaxillary

elastics;

• The roots are then uprighted as a separate procedure using auxiliary springs.

2. It is much easier to tip a tooth than move it bodily and this requires less force, so the Begg

technique was much lighter on anchorage and became very popular during the 1960s and

1970s .

Begg appliance design

The original light wire appliance was the Begg appliance, which utilized a simple bracket

that was identical for each tooth.

Begg brackets incorporate a narrow open-ended slot, into which a stiff round archwire is

placed from the gingival aspect and held in position by the insertion of a small metallic

auxiliary lock pin

The loosely fitting round wire allows considerable scope for the teeth to tip under the

influence of light intermaxillary elastic traction, which in combination with anchor bends

placed in rigid archwires, allows rapid reduction of both overbite and overjet during initial

treatment.

Following this, a variety of auxiliary springs is required to upright and torques the teeth

into the correct position.

Tip-Edge appliance

Because Begg appliance only uses round archwires, precise finishing is difficult and the

use of auxiliaries in the final stages of treatment to upright teeth that often have been

tipped through quite significant distances proved to be quite complex, difficult to control

and also time-consuming.


In an effort to address this, the Tip-Edge appliance was developed by Peter Kesling in the

late 1980s (Kesling, 1988; Kesling et al, 1991).

This appliance also tips the teeth during the initial phase of treatment, but allows later

uprighting with more rigid three-dimensional control by closing the slot down around

full-size rectangular archwires

Tip edge appliance, same prescription of Roth except

L incisor increased tip

Canine less torque

Premolar tip and torque midway bet Roth and Andrews

Molar : upper as Andrews and lower with reduced torque

More recently, the Tip-Edge PLUS bracket has been introduced, which eliminates the

need for auxiliary springs by incorporating a tunnel deep to the main bracket slot. A

superelastic auxiliary archwire placed into this tunnel during the final stages of treatment

provides the uprighting forces necessary for the bracket prescription to be expressed

(Parkhouse, 2007).

Self-ligating brackets

The concept is not new, having been originally pioneered in the 1930s. However, these

bracket systems have undergone a renaissance over the past two decades, largely because

of enhanced ingenuity and reliability.

Lingual bracket

1. Developed in 1975 by Kruz USA and Fujita Japan

2. It is mainly fully programmed appliance (means that all SWT feature are

involved) and either semi or fully customized to the patient.

Straight wire appliances (SWA)

The Straight-Wire Appliance was originally developed by Larry Andrews in 1976 and is a

fully preadjusted edgewise appliance based on Andrews' six keys to occlusion (Andrews

1972).

Some terminology in SWA

1. Bracket base: the most lingual portion of the bracket stem

2. Slot Base: the lingual wall of the slot.


3. Slot point the centerline of the slot. It is equidistant from the gingival and occlusal slot

walls and is centered mesiodistally.

4. Slot axis: the line connect slot and base point

5. Bracket Stem: the portion of a bracket between the bracket base and the slot base.

6. Base Point: it is a point on the bracket base at the extension of the slot axis.

Features of SWA as describe by Andrews

1. Primary design features LIKE vertical and horizontal countered bracket, torque in base,

tip in bracket, in and out offset

2. Siting features: these are design features which site the bracket slot in a correct position

(i.e. slot base coincident with FA while the bracket base contoured with the tooth surface

when the clinician correctly positions the bracket vertically and horizontally.

3. Auxiliary features: these contribute to the biologic aspects of treatment but are not

involved with siting the slot. e.g.: power arms, facebow tubes, auxiliary tubes, parallel tie

wings, rotation wings

4. Convenience features: convenience features are not involved in siting the slot or

contributing to the biologic aspects of treatment but which make the appliance easier to

use or more comfortable to the patient. e.g.: extended gingival tie wings, facial contouring

of brackets, bracket identification, bracket material.

Advantages

Roth, 1976

1. Ease of arch wire construction and placement.

2. Cleanliness and patient comfort due to absence of the wire bending

3. Better rotation control: Since there are no bends in the arch wire, an inter-bracket span

of any great magnitude is unnecessary to reduce the force level; therefore, wide Siamese

brackets can be employed to control rotations.

4. Less "round-tripping." Since the teeth move in more direct vector lines from their

maloccluded positions to their individualized positions, there is less "round-tripping" of

the teeth.

5. Better control of tooth positions and finishing. Thus there is a more consistent result

with shorter treatment time.


6. Complete space closure in both extraction and non-extraction cases can be accomplished

with one set of arch wires since there are no bends in the arch wires to interfere with the

brackets themselves during space closure.

7. Bracket Identification. As follow:

Upper central incisors black

Upper lateral incisors pink

Upper canine green

Upper premolars purple

Lower central and lateral incisors yellow

Lower canine blue

Lower first premolar black

Lower second premolar white

Disadvantages

1. Friction

2. Perceived anchorage demands

3. Technical, biological and mechanical variability still requires adjustments in the

appliance to accommodate this. Greekmore, 1993 described some reasons why current

preadjusted orthodontic appliances do not achieve ideal tooth positions with the use of

"straight" wires.

A. The most frequent reason is inaccurate bracket placement. Solution: indirect positioning.

B. Variations in the malocclusion require variations in the positions of maxillary and

mandibular incisors. Solution: use customized bracket, cephalogram analysis to determine

the prescription needed.

C. Variations in tooth structure, such as irregular facial surfaces, crown-root angulations.

Solution: use customized bracket.

D. Edgewise orthodontic appliances have some significant mechanical deficiencies:

Force application to teeth through brackets located away from the center of resistance,(use

lingual bracket or exaggerated prescription)

Play between the arch wire and the arch wire slot (slop).

The reason for the slop

1. The amount of the play between slot and wire.

2. Lack of stiffness in the AW


3. Lack of stiffness in the bracket slot as in acrylic bracket

4. Incomplete ligation

5. Oversized slot and undersized wire

Bracket positioning

1. Individualized bracket positioning

2. Standardized method

3. FACC

4. Progressive positioning by Pitts

5. Mid-point of the crown

In details

1. Standardized method: With the original edgewise appliance, bracket placement was

normally carried out using standard millimeter measurements using a gauge from the

incisal or occlusal edge of each tooth, irrespective of tooth size. The brackets were

positioned at different curvature on the teeth, and this in turn led to variations in the

amount of torque and in-out produced by the brackets. However, because archwire

bending was needed in any case, this system was acceptable with the edgewise appliance.

2. FACC: Andrews introduced the concept of the FACC. The FACC (facial axis of the

clinical crown) is for all teeth except for molars, the most prominent portion of the central

lobe on each crown's facial surface. On molars, the FACC is represented by the buccal

groove that separates the two mesial buccal cusps. The FA (facial axis) point is the

midpoint of the FACC. However, as described below, it proved difficult to obtain

accurate vertical positioning using only the middle of the clinical crown.

3. Individualized bracket positioning (Thicket 2007)

Variation in occlusal-gingival positioning with more gingivally in AOB and occlusally in

deep bite case.

Variation in torque application:

Variation in MD positioning

Variation in angulation: Where teeth have to be translated a significant distance (such as

in pseudo transposition cases) there is an increased tendency to tip and so the brackets

should be angulated to prevent this; this often requires a significant overangulation of the

bracket. A similar situation occurs where implants are to be placed post orthodontic


treatment and the tooth roots must be parallel to one another to leave room for the

implant.

4. Progressive positioning by Pitts: A more modern take on bracket positioning is given by

Pitts (2009). Pitts places brackets more gingival (posterior-anterior progressive

positioning) than normal and using the mesiodistal contact points of the teeth as a

reference line (the M-D contact line)

5. Mid-point of the crown: McLaughlin and Bennett advocate the use individualized

bracket-positioning charts. From this data, a placement chart was devised from which the

user selects the row of bracket heights which most closely corresponds to the half clinical

crown height of the dentition to be bonded.

McLaughlin and Bennett determined ideal bracket placement positions based on the

midpoint of the clinical crown using data on:

1. anatomical crown heights

2. clinical crown heights

3. American Boards or Angle Society cases

4. debonded cases that had settled into a good six keys occlusion

They found minor deviations of the centres of the clinical crowns on the:

1. upper premolars

2. the upper second molars

3. lower canines

4. lower first molars


Exceptions to full bracket placement

1. Cases with unerupted teeth, or teeth significantly out of the arch form

2. Deep-bite cases in which the upper incisors interfere with bracket placement on the lower

incisors, the upper incisors can be bracketed and the lower incisors left unbracketed at the

start of treatment or a biteplate can be placed at the initial bonding visit, provided the

occlusion allows this.

3. Deep bite with distally inclined canine

Creating the bite-plate effect to allow full placement of the bracket

There are four methods of creating the bite-plate effect:

1. Appliances can be placed on the upper arch only, which allows for proclination of the

upper incisors. This frees the lower incisors for placement of brackets. This technique is

helpful in high-angle cases, because posterior extrusion is minimized.

2. Acrylic removable anterior bite plates can be placed. The disadvantage of these removable

appliances is that they are not always worn by the patient. Also, tooth movements lead to


improper fit of these appliances after a relatively short period of time. Lastly it should be

used in growing patient unless clockwise rotation of the mandible is required.

3. An adequate substitute for a removable bite plate in low angle deep-bite cases is the

placement of direct bonding material on the palatal surface of the upper incisors . Colored

adhesives such as BandlockIM from Reliance or Transbond Plus™ from 3M Unitek are

useful and can be easily removed from the tooth surfaces after bite opening. Sometime the

use of ready-made metal or plastic bite turbo can be used.

4. In average- to high-angle cases, the placement of similar colored adhesives on the occlusal

surface of the first molars is helpful in bite opening. This adhesive can be progressively

removed as the bite opens.

Horizontal accuracy during bracket positioning

1. It not significantly affect incisors because of their flat surface but it affect canine and

premolar.

2. It is better to be checked by mirror

3. In lower canine it is better to positioned it more mesially to ensure good contact with lower

incisors.

4. In rotated teeth better to position it more toward the rotated surface

Axial accuracy during bracket positioning

The bracket wings need to be parallel to the long axis

Vertical accuracy during bracket positioning

Accuracy is greatly improved by the use of gauges and an individualized bracket-positioning

chart. This will deal with difficulties such as

Tooth length discrepancies,

Fracture tooth

Labially and lingually displaced roots,

Partly erupted teeth,

Gingival hyperplasia

Variation in positioning during bracket placement

1. In non-extraction cases the bracket positioned at the middle of crown at LA point but in

extraction cases it should be more 1mm gingival to increase torque expression which if

incorrect might cause some marginal discrepancies between 3 and 5.


2. Fractured or worn incisal edges (or cusp tips) should be restored, in the orthodontist's

mind's eye, prior to bonding or banding, rather than position the attachments too

gingivally and extrude the teeth. Failure to do so leads to incorrect height of gingival

margins, cingulae and marginal ridges. It is recommended that the first incisor bracket

placed in each arch should be on the tooth with the most natural shape and crown height.

The brackets on the other teeth can then be adjusted to the same distance from the incisal

edge, regardless of their gingival contours

3. Premolars: As a general rule, inexperienced orthodontists tend to place the buccal

segment brackets too occlusally, particularly in the lower arch. This results in infra

occlusion, incorrect torque and, for the lower arch, the increased likelihood of the

brackets being bitten off.

4. Molars:

It is important for a similar amount of mesial and distal buccal cusps to be visible above

the band to ensure a correct mesio-distal angulation.

It is preferable to show more mesial cusp than distal cusp, particularly where premolar

extraction therapy is involved.

It is also necessary to ensure appropriate seating of the band on the palatal and lingual

sides in order not to prejudice the torque expression.

The banding of second molars also deserves particular attention. As a general rule, it is

desirable for the tubes on the second molars to be 2 mm to l mm more occlusal than on

the first molar in order to prevent the second molars from taking the majority of the forces

of occlusion. This is particularly important in high angle cases where banding the upper

second molars is mandatory to ensure that the palatal cusps do not hang low and cause

interference.

5. Local bracket variations

A. Canine in lateral incisor positions

Some clinicians advocate bonding lateral incisor brackets on these canines

The preferred option is to fit Andrews canine brackets upside down.

The same effect can be achieved by bonding an inverted premolar bracket, either Roth,

Andrews or MBT.

B. Palatal laterals

The use of full thickness archwires.

Torque auxiliary

Making third order wire adjustments for individual root torque.


A more elegant solution is to fit an Andrews lateral incisor bracket upside down.

C. Lower canines angulation in Class III cases

1. The answer is to bond contra lateral brackets (i.e. 13 bracket bonded on 31 and vice

versa).

2. Not only does the adaptation enable dento-alveolar compensation, it also reduces the

anchorage requirements

D. Second premolar extraction

A relatively common observation where 515 have been extracted is for inadequate root

paralleling with excessive apical separation between the first premolars and molars at the

end of treatment. This problem can be dealt with by applying a combination of measures.

The use of a Roth molar tube is helpful,

Mesial tipping being further reduced by ensuring the molar band is well seated mesially.

Banding second molars and keeping the appliance in place for several weeks following

space closure are also advisable.

The premolar bracket can be bonded at a slight angle to ensure full apical correction

during space closure.

E. Risk of unwanted lower incisor proclination

The use of lower incisor brackets with -6° torque (lingual crown torque) is equivalent to

introducing 5° torque in the archwire.

F. First molars in Class II occlusion after extraction of two maxillary premolars

The great majority of cases are treated to a Class I molar relationship but, occasionally,

the aim is to achieve a Class II molar inter-digitation. The accepted good molar position

with a slight mesial angulation and disto-palatal rotation is inappropriate in a Class II

occlusion.

The Andrews prescription which has 5° mesial angulation is particularly inappropriate as

these results in the mesial marginal ridge being totally out of occlusion. The relevance of

rotation is that, in a Class II occlusion, the upper molar mesio-buccal cusp needs to be

tucked in between the lower second premolar and first molar, and the disto-buccal cusp

needs to be more buccal to avoid an edge to edge occlusion with the lower molar.

What is required is a tube prescription which has 0° mesio-distal angulation, 0° rotation

but maintains 14° buccal root torque. Tubes with a 0, 0, 14 prescription are available in

either triple or single configuration. It is recommended these should be stocked in small


numbers for direct bonding or welding onto plain bands in order to avoid the high cost of

pre-welded stock. Incidentally, this prescription is also highly suitable for many

orthognathic cases.

Other option includes swapping the contralateral second molar MBT tubes and uses it on

the first molars.

Bracket bonding

Bracket bonding can be achieved in two ways:

1. Direct bonding places the brackets on the teeth individually at the chairside;

2. Indirect bonding places the brackets on study models in the laboratory and these are

transferred to the teeth using a positioning tray. The advantage is greater accuracy of

bracket positioning; however, the extra cost and time involved make this process less

popular for routine orthodontics with labial appliances, although it is used when placing

lingual fixed appliances. Orthodontic brackets are generally bonded to enamel using

mechanical locking created by acid-etching the enamel surface of the teeth.

Indirect bonding (Thomas 1979)

ADVANTAGES OF INDIRECT BONDING

1. Accurate bracket placement

2. Optimizing the use of doctor’s time

3. Avoiding band fitting on posterior teeth

4. Eliminating the need for separators

5. Improved ability to bond posterior teeth

6. Improved patient comfort and hygiene

DISADVANTAGES OF INDIRECT BONDING

1. Technique sensitive

2. Additional set of impressions needed

3. Posterior attachments more likely to fail if patient chews ice, etc.


SAW prescriptions features

The most common prescriptions used seem to be:

1. Andrews,

2. Roth

3. MBT.

For all prescriptions, the prominence values (in-out first order bend) are the same and so

the only variables within a prescription are:

1. Angulation

2. Inclination

3. Offset (counter-rotation)

4. Offset gingival pad brackets

In details

Prominence

Prominence or in/out or first order correction: it is an adjustment built into the bracket

base to compensate for the differing buccolingual thickness of teeth.

Angulation

Angulation or tip is built into brackets to ensure that teeth are placed at a specified

mesiodistal angulation. Tip is built into brackets in the Straight-Wire Appliance by cutting

the slot at an angle to the vertical axis of the bracket and not by rotating the bracket base

in relation to bracket stem. This ensures that the bracket sits squarely on the surface of the

tooth.

Inclination

Inclination or torque. It may be placed in a preadjusted bracket by putting the torque in

the face or in its base of the bracket.

1. Torque in the face is achieved by cutting the slot at an angle to the face of the bracket. For

this type of bracket, the slot axis will not be

coincident with the base point. As the slot point may


be used instead of the base point to position the bracket, then the vertical discrepancies

between these points will become greater as increasing torque is put into the bracket.

Brackets with torque in the face will therefore have vertical positioning errors due to the

discrepancy between the slot point and base point in these brackets and the fact that the

base point cannot lie on the slot axis unless there is zero torque in the bracket. These

vertical positioning errors will in turn affect the expression of in/out & torque built into

the bracket. The magnitude of these vertical errors is dependent on the amount of torque

built into the bracket but does not exceed 0.7 mm in the lower arch or 0.5 mm in the upper

arch in either the Andrews or Roth prescriptions. However the vertical positioning errors

of this magnitude are unlikely to be clinically significant.

2. Torque in the base of the bracket is built-in by adjusting the size of the triangle of metal in

the base of the bracket (base stem). Until comparatively recently this was a patented

feature of the Straight-Wire Appliance in the USA but not in Europe. Torque in the base

ensures that the base point and the slot point are coincident.

Choice of the torque prescription

It depends on

1. Population sample

2. Where the bracket position is aimed by the inventor

3. Type of malocclusion

4. Mechanics of treatment

5. Treatment plan: Exo or non exo

6. Amount of the play between the slot and the wire which is known by the company

Offset (counter-rotation)

Offset (also known as counter-rotation in translation series brackets) is built into upper

buccal tube assemblies, premolar, canine, incisor brackets and lower molar tubes in

translation series prescriptions to counteract the tendency of teeth to tip into the extraction

space during space closure.

This rotational correction tends to rotate teeth mesially anterior to the extraction site and

distally distal to it.

Offset gingival pad brackets

These brackets were originally described by Swartz in 1994. Bonding premolars is

traditionally difficult because:


1. The short clinical crown

2. Enamel abnormalities in the gingival third with more aprismatic enamel at this region. At

this region, the enamel rod direction that is more divergent from perpendicular and thus

less retentive of resin tags

3. Improve bond strength by increasing the pad size by utilizing more of the coronal enamel

for retention and less dislodgement because the opposing teeth are away from contacting

the bracket wings

4. Reduce gingival impingement.

5. Correct positioning of the slot in relation to FA.

6. Easier to place

7. Easier ligation

However, an RCT had been carried out by Tidy and Coley-Smith (1998) which shows

that gingival offset brackets have a risk of bond failure which is five times more than with

conventional brackets. This corresponds to the more anecdotal improvement suggested by

Swartz (1994). Also, Thrend 2004 show more bond failure in offset bracket

Slot Height and depth

Edgewise brackets have rectangular slots, which are deeper in the horizontal as opposed

to vertical plane. Slot and archwire dimensions have traditionally been described

empirically, with the original dimensions being 0.022 inches vertically and 0.028 inches

horizontally to accommodate gold archwires, which were quite soft. Once stiffer stainless

steel archwires were introduced, slot size was reduced to 0.018 inches vertically and

0.025 inches horizontally. However, with greater uptake of preadjusted edgewise systems,

there has been a move back to the original slot dimension.

Advantage of 022 over 018 slot1. It gives lighter forces in the early stages of treatment by providing more slop in the

early stages of treatment

2. Better control of tipping during sliding

3. Better control of rotation during sliding

4. Better expression of torque

5. Better control of OB

6. Better control of arch width

7. Better stabilization of segment after orthognathic surgery


8. Multiple wire size selection

Disadvantage of 0221. High friction

2. Multiple wire sequence until the working AW is reached

3. Root resorption

4. Full size wire in the finishing cause Heavy force (normal torque force 60g per tooth), to

overcome this:

Use undersize wire with added torque

Use flexible materials

Use super torque bracket with under size wire

Use torque auxillary

NB:

A study by Cash et al 2004, found that most of the bracket slot are height oversized and

the wire are height undersized.

Depth of the bracket are 028 except in Damon are 027 at LLS to provide more rotational

control

Types of SWA

Andrews prescriptions

Incisor bracket sets

Andrews (1989) described different incisor bracket sets for use in different skeletal

patterns:

1. The Set A bracket set, designed for Class 2 skeletal patterns more less palatal root torque

in the upper incisors to facilitate the establishment of a normal incisor relationship

whereas

2. Set C for Class 3 skeletal patterns had the reverse.

3. Set S was for Class 1 malocclusions.

Translation (extraction) series brackets


Translation brackets were introduced by Andrews (1989) to compensate for the unwanted

tooth movements that occurred during closure of extraction spaces. These posterior

bracket sets (i.e.: molars, premolars and canines) had increased tip and antirotation

according to how much translation of the tooth was expected.

1. Minimum 0-2mm (T1)

2. moderate 3-4 (T2)

3. Maximum 5mm (T3) bracket sets are available.

4. T4 brackets are molar brackets without the five degrees of tip in the standard prescription.

Harradine and Birnie (2001), however, feel that there is not enough torque in the upper

labial segment in the Andrews prescription.

The mesial angulation built into the Andrews tube is the result of the observed angulation

of the first molars in his sample of 120 adults with ideal occlusion. However, the use of

this prescription is inappropriate clinically for the following reasons:

1. At the completion of treatment, at the age of approximately 14, the facial complex is still

growing downwards and forwards. Molar crowns left upright at this age will assume the

mesial angulation found in the adult ideal dentition by the time the patient ceases

growing. But leaving a patient with mesially angulated upper first molars at the age of 14

may result in over-angulation by the time growth is complete.

2. Treating a malocclusion to a mesially angulated upper molar position is more anchorage

demanding as the roots of the upper molars have to be moved more distally.

3. Treatment based on headgear with Andrews’s tubes is more liable to cause iatrogenic root

resorption of first molars against unerupted second molars.

Roth prescriptions

The objectives of Roth in his treatment are

1. Pleasant aesthetic

2. Stability of treatment depends of good functional occlusion.

3. TMJ problem less in good occlusion

For these reasons the prescriptions are:

1. More torque in the upper incisors than Andrews one because it is an extraction series

bracket.


2. The upper canines have additional tip and less torque while lower canine has increased tip

than in the standard prescription which facilitates canine guidance as a fundamental for

functional occlusion.

3. The Roth prescription gives more torque in the upper molars to prevent dropping of the

palatal cusps.

4. Since the prescription is extraction based, there is anti-tip and anti-rotation built into the

buccal segment brackets.

5. Lower incisor bracket are set C series bracket

MBT VERSATILE +

The Bennett-McLaughlin prescription follows the Andrews prescription closely. MBT™

treatment philosophy is:

A. Bracket design

1. Mid-size metal brackets

2. Rhomboidal shape,

3. Torque in base

4. The .022 not the .018 slot

5. Thicker 0.5mm bracket on upper second premolar if they r small

B. Light continuous forces

C. Anchorage control early in treatment. This achieved by

1. Light force

2. Reduced tip

3. Bendback

4. Laceback

D. Bracket positioning chart

E. Archwire hooks

F. Enmas space closure

G. Aspects of versatility

For upper set of bracket

1. Options for palatally displaced upper lateral incisors (-10°).

2. Three torque options for the upper canines (-7° , 0° , and +7°).

3. Interchangeable upper premolar brackets - the same tip and torque.

4. Use of upper second molar tubes on first molars when HG not used.

5. Three torque options for lower canines (-6° , 0", and +6").


6. Bondable mini second molar tubes for partially erupted teeth

7. Different upper 5 bracket thickness

For lower set of bracket

1. Interchangeable lower incisor brackets - the same tip and torque.

2. Use of lower second molar tubes for the upper first and second molars of the opposite side,

when finishing cases to a Class II molar relationship. Also the tube is placed at a different tip

position, with more enamel from the mesial cusp visible than from the distal cusp. This

introduces the necessary tip adjustment.

3. Different lower 5 bracket thickness

4. Lower 5 tube which help to control sliding, avoid interference with upper, clean, easy and

quick

5. Lower first molar non-convertible tubes to reduce its thickness

6. Lower first molar double tube and upper first molar triple tube attachments

7. Bondable mini second molar tubes for partially erupted teeth

H. Bracket prescription

1. Increased maxillary incisors labial crown torque

a. For class II D I:

It may be help in expressing the palatal root torque in undersized wire

It helps to counteract the side effect of functional appliance

It helps to counteract the side effect of class II elastic

help in the reduction of OB by proclining the ULS.

It helps to counteract the effect of retroclination during space closure

But the wagon wheel effect will be expressed due to increase in the torque which will result

in reduction of the expression of the mesial tip of ULS and this will reduce the anchorage

demands. For each 4 degree increase in the torque there is 1 degree reduction in the mesial

tip.

b. For class II D2, same as class II D1

c. for class III it help to express the camouflaging effect of ULS

2. Increased lingual crown torque of LLS

a. For class II D I and class II D2


It helps to counteract the side effect of class II elastic by preventing the LLS proclination

It helps to counteract the side effect of functional appliance

it helps to counteract the effect of RCOS during deep OB correction or when using utility

arch

b. For class III it help to express the camouflaging effect of LLS

3. Increased buccal root torque

Counteract the tipping of expansion by expander or functional in class 2 and class3

Increase anchorage by cortical bone theory

Better intercuspation

4. Reduced lingual root torque of lower posterior teeth

Provide better intercuspation

Counteract the rolling effect of class II elastic or during space closure in the lower arch

It reduce the chance of gum recession

5. Upper molar offset at 10 degree

counteract the unwanted rotational movement during space closure in the upper arch and this

might strengthen the anchorage

Aid in class I Andrews molar relationship

6. Zero degree tip of upper molars

This is called effective tip, because when we place the tube, it is parallel to the occlusal

surface which already tipped 5 degree forward. the same applied for lower molars

Provide better intercuspation

To keep the molar upright while the future growth might cause further mesial tip. This is

because the MBT mainly used in growing patients.

Also this might reduce the anchorage demand

Prevent distal tipping of the root of the first molar against second molars which might cause

further root resorption when HG is used

7. Reduced canine tip compared to Roth

To reduce the anchorage demand


There is a variety of canine tip prescription and uses according to the clinical scenarios as

follow:

A. Arch form: in narrow arch use +7 to avoid dehiscence

B. Canine labio-palatal position: in buccaly positioned canine, better to used +7 to avoid

dehiscence

C. Extraction: if the canine wanted to be retracted distally, use +7 to make the root in the middle

of the canceller’s bone

D. Expansion: use -7 in the upper

E. Missing lateral: use +7 in upper

Why MBT less anchorage demand

1. Light force

2. The wagon wheel effect: because increasing the torque will cause the mesial tip of ULS to be

reduced and this will reduce the anchorage demands

3. Reduced canine, premolar and molar tip compared to Roth

4. Increased molar root torque buccally, increase anchorage by cortical bone theory

5. Upper molar 10 degree offset, counteract the unwanted rotational movement during space

closure in the upper arch and this might strengthen the anchorage

Damon system

The Damon prescription is similar to the Andrews prescription but with less tip on the

canines and the option of increased upper incisor torque and the class 3 lower incisor set.

Comparison of bracket prescriptions

MaxillaryPrescription1

Ti/To/Ro

2

Ti/To/Ro

3

Ti/To/Ro

4

Ti/To/Ro

5

Ti/To/Ro

6

Ti/To/Ro

7

Ti/To/Ro

Andrews5/7/09/3/011/-7/02/-7/02/-7/00/-9/100/-9/10


Roth5/12/09/8/013/-2/40/-7/20/-7/20/-14/140/-14/14

MBT4/17/08/10/08/-7/00/-7/00/-7/00/-14/100/-14/10

Mandibular

Prescription1

Ti/To/Ro

2

Ti/To/Ro

3

Ti/To/

Ro

4

Ti/To/Ro

5

Ti/To/Ro

6

Ti/To/Ro

7

Ti/To/Ro

Andrews2/-6/02/-6/05/-11/02/-17/02/-22/02/-30/02/-31/0

Roth2/-1/02/-1/07/-11/2-1/-17/40/-22/4-1/-30/4-1/-30/4

MBT0/-6/00/-6/03/-6/02/-12/02/-17/00/-20/00/-10/0

Components of fixed appliances

1. Brackets and molar tubes

2. Archwires, which are attached to the brackets and pass through the molar tubes;

3. Auxiliaries, which will vary between appliance types, but include bracket ligatures, pins,

elastics, uprighting and torquing springs, ligature wires and fixed devices for anchorage

reinforcement or arch expansion.

Bracket materials

1. Metal (SS, CrCo,NiTi, gold)

2. Aesthetic brackets

Transparent bracket

A. Ceramic

B. Polycarbonate(very weak and creep under force)

C. Polyurethane or reinforced polycarbonate

Lingual bracket


In details

Stainless steel bracket

1. Stainless steel bracket (Iron 71, Nickle 8, Cr 18, carbon)

2. 10% of people in US have allergy to nickel however mucosal reaction is very

insignificant when patient has allergy and almost he can withstand it even if her skin is

allergic to nickel.

3. Construction:

Castable,

Milled,

Metal injection moulding

Titanium

1. Used in allergic pt to nickel. It is more wettable than SS so it bond better to

bonding materials.

2. Titanium: covered by layer of Ti to reduce friction

CrCo.

1. Less nickel sensitivity and less release of nickel

2. Harder than stainless steel.

3. More friction than stainless steel brackets.

Aesthetic and ceramic bracket

Polymer like

1. Polycarbonate

2. Polyurethrane

3. Metal reinforced polycarbonate or polyurethrane

The main problems encountered were

• Weak bond strength,

• Distortion of the bracket from the wires

• Fracture or wear of the bracket


Ceramic brackets

Types

4. Polycrystalline(opaque) eg Transcend

5. Monocrystalline(very hard and translucent) eg Saffire

6. Metal reinforced polycrystalline

7. Others eg Zirconia

8. Hybrid

1. Polycrystalline

• Aluminium silicate particles are mixed with a binder and injected into a mould.

• The mould is then heated to 1800 degrees C.

• Machined with diamond tools, ultrasound or lasers to prepare bracket slot.

Advantages

It can be moulded, therefore can be produced in large quantities and at a low cost.

Disadvantages

1. Structural imperfections

2. High friction.

3. Opaque.

4. Low fracture toughness.

2. Monocrystalline

1. Machined by milling synthetic Safire.

2. Aluminium oxide particles are melted (heated to over 2100 degrees C)

3. Then cooled slowly and then milled

Advantages

1. Less imperfections and impurities,.

2. Clear

3. Lower friction

Disadvantages

1. Expensive

2. Low toughness


Metal reinforced polycrystalline

The most successful ceramic bracket is the Clarity bracket which goes some way

towards addressing some of the problems by incorporating a metal slot to reduce friction

and a weakness in the base to allow easier debonding.

Zirconia

Similar properties to alumina (polycrystalline) brackets.

Problems with ceramic brackets,

Karamouzos, 1997, Bishara 2000

1. Bracket placement

2. Bracket ligation

3. Bracket fracture

4. Friction

5. Enamel wear

6. Bond strength and debonding

7. Cost

In details

Bracket placement

Problems:

1. Visual information is not as good.

2. Bracket markers help in bracket positioning but it might make the removal of the

excess bonding material more difficult.

Solutions:

1. Visualise from different angles.

2. Immediate clean up and coloured adhesives are helpful.

3. Using transfer gauge

4. Indirect bonding

Ligation

Problems:

1. Clear and tooth coloured elastic ligatures tend to discolour.


2. Metal ligatures are obvious under clear brackets.

3. Ligatures lockers can fracture the brackets.

Solutions:

1. Use opaque brackets (Clarity).

2. Use Teflon coated ligatures or 'white' elastomeric modules.

3. Use thin Quick Ligs, which must be fully tied in with the twisted tails tucked

under the archwires.

4. Self-ligating ceramic brackets (Damon clear)!!!!!!

Bracket fracture

1. Results from lack of ductility and low fracture toughness (Birnie 1990). eg tie

wings fracture or fracture of the brackets on debond.

2. Ceramic brackets are not recommended for

Orthognathic patients,

Small teeth,

LLS,

Deep OB.

Use low profile bracket

Friction

Problems:

1. Relatively rough surface of the ceramic slot significantly increases frictional

resistance.

2. Hard ceramic abrades stainless steel wire.

Polycrystalline ceramic brackets are manufactured either by an injection moulding

process, which produces a smooth surface texture, or by milling or machining with

diamond tools, resulting in a rougher final surface texture.

Solutions

1. Perfecting the slot surface eg lined bracket slot or by using lower friction ceramics

eg zirconium oxide.

2. Use ceramic brackets with metal lined slots. Nishio et al. 2003 demonstrated

significantly higher frictional forces with ceramic brackets with metal slots compared to


stainless steel brackets. The difference is probably due to the difficulty in adapting the

metal sheath to the ceramic slot and due to their different expansion coefficients

3. Use closing loops rather than sliding mechanics.

4. Avoid bonding premolar teeth during space closure

5. Use metal premolar bracket.

6. Change arch wires each visit.

7. Consider the following

Rectangular AWs > Round

NiTi and TMA > Stainless steel

Enamel wear

Ceramic is 7 times harder than enamel. In vitro wear visible after only 15 chewing

cycles (less than one meal).

Solutions

1. May have to restrict use to upper arch only.

2. Must not bond teeth where there is an occlusal interference.

3. Use Glass ionomer cement to dis-occlude the teeth if the lower are bonded with

ceramic brackets.

4. Advance the upper incisors before bonding the lowers as in class II D2 cases.

5. Using polycarbonate bracket in case of deep overbite (Russell, 2005)

6. Rubber ligatures over tie wing slot can preventing contact of the opposing

dentition with the ceramic bracket, are a further method of reducing the risk of enamel

damage (Russell, 2005)

7. Use low profile bracket

Bond strength

It can be very strong with potential for enamel damage.

Solutions

I. Avoid the use of ceramic bracket in the following scenarios

1. Heavily restored teeth,

2. Non-vital ,

3. Perio involved

4. Lower incisors

5. Thin labial enamel

6. Small teeth,


7. Cracked enamel

II. Addition of certain features to reduce bond strength

1. Moderate mechanical retention features, grooves etc

2. Use meal mesh in base (but poor aesthetics)

3. Reduce silane coupling

4. Select weaker bonding resin

Enamel fracture and debonding

1. Risk of bracket fracturing and being inhaled, swallowed or flying ceramic

fragment missile.

2. Sharp fragments may be left on teeth requiring time consuming removal with a

diamond bur in a high speed handpiece.

Solutions

1. Protect eyes and airway.

2. Remove excess of the bonding from around the bracket before debonding

3. Keep a finger over the bracket to prevent it becoming a projectile;

4. Apply the debonding pliers on the mesial and distal of the bracket;

5. Main force is squeezing (at least 75%), and very gently twist

6. Specialised debonding techniques like:

Special debonding pliers

Ultrasonic instruments

Electro-thermal to soften adhesive prior to debonding

Laser debonding

3M unitek incorporate a stress concentrator at the base of the bracket to make their

removal easy.


Cost

Basically ceramic brackets are EXPENSIVE

Advantage

THE ONLY CURRENT ADVANTAGE OF CERAMIC OVER METAL BRACKETS

IS....AESTHETICS

Clinical requirements of the orthodontic wires

A. Aligning

It is defined as vertical levelling between adjacent teeth also takes place but not for

the arch as a whole.

Types of aligning wire:

1. Looped stainless steel

2. Elgiloy

3. Multi-strand stainless steel wires

4. Nickel titanium alloy wires

The appropriate wire for this stage has to exhibit

1. Good springiness,

2. Low stiffness,

3. Shape memory

4. Continuous force

5. Small diameter: Easy movement of the wire through the bracket thus promoting efficient

leveling and aligning. Therefore a wire of small diameter is at an advantage. Major

drawbacks include cost and rollercoaster effect

Canine:

It should be constantly borne in mind that any attempt to save time by applying

excessive force in retracting canines has the adverse effect of tipping the crowns distally,

so reversing root uprighting, deepening the overbite, distorting the arch form and wasting

anchorage. This will simply lead to prolonged re-uprighting thus extending overall

treatment time and a possible crisis in anchorage management.


The mesial tip in the brackets of the SWA particularly that of the canines, makes this an

anchorage demanding phase of treatment, more so if the canines are distally angulated.

Because of this unique feature, care during aligning is paramount for successful treatment.

B. Retraction of individual tooth to relief crowding or ML correction at the initial stage

The base arch, normally .018 or .017 x .025" stainless steel, has to exhibit good stiffness

and strength to resist distortion during the movement of teeth along the wire

C. Overbite control & Space closure

OB control

The wire used for this purpose are:

19*25ss flat or with curve

19*25 rocking chair

Auxillary AW

Segemental or sectional AW

The Straight Wire Appliance controls overbite in two distinct stages:

a) The correction of the mesio-distal tip of the teeth, particularly the canines, in the initial

stages of levelling and aligning.

b) Having corrected the tip of the teeth, the correction then occurs in the vertical plane by

the following methods which are common to all types of mechano-therapy.

i) Extrusion of the posterior teeth.

ii) Intrusion of the anterior teeth.

iii) Proclination of the labial segments.Space closure is accomplished with auxiliaries.

Space closure

1. Sliding mechanics: Various forms of elastic traction, closing modules, powerchain, elastic

bands, Niti closing coil springs have been shown to produce more rapid and consistent

space closure (Samuels, 1993).

2. Closing loop mechanics

D. Torque control

1. The base arch for the final stage of treatment is .019 x .025 SS

2. When individual torque is needed, eg. if 2 or 3 have palatal roots, a wire is needed which

can produce a much lower force over a longer range such as

3. .019 x .025 TMA. The downside is the loss of overbite control.


Archwire sequence guide

The general concept is to think in terms of four main wires, around which other wires are

used as intermediate 'stepping stones' between the main wires

or to achieve specific objectives.

Four main wires:

1) .014 or .016 nickel titanium aligning arch, either active austenitic or active martensitic

depending on the degree of malalignment. It is easier to fully engage martensitic wire as it

is softer at room temperature.

2) .018 round stainless steel base arch for sliding individual teeth mesio-distally, usually to

close labial segment spacing or to retract canines.

3) .017 x .025 SS or .018 x .025 Niti to initiate correction of torque differential in adjacent

teeth.

4) .019 x .025 stainless steel final base arch for overbite control, torque and space closure.

5) Intermediate 'Stepping stone' wires: usually From 1) to 2)

If starting with .014 Niti, a .018 Niti or .016 Steel wire may be necessary for 4 to 6

weeks.

Early use of square (.020 x .020) Niti is particularly applicable where torque discrepancy

is high before engaging 19*25 NiTi.

However a study by Mandal et al 2005 showed the following: The aim of this study was

to compare three orthodontic archwire sequences. One hundred and fifty-four 10- to 17-

year-old patients were treated in three centres and randomly allocated to one of three

groups: A = 0.016-inch nickel titanium (NiTi), 0.018 × 0.025-inch NiTi, and 0.019 ×

0.025-inch stainless steel (SS); B = 0.016-inch NiTi, 0.016-inch SS, 0.020-inch SS, and

0.019 × 0.025-inch SS; and C = 0.016 × 0.022-inch copper (Cu) NiTi, 0.019 × 0.025-inch

CuNiTi, and 0.019 × 0.025-inch SS. At each archwire change and for each arch, the

patients completed discomfort scores on a seven-point Likert scale at 4 hours, 24 hours, 3

days, and 1 week. Time in days and the number of visits taken to reach a 0.019 × 0.025-

inch SS working archwires were calculated. A periapical radiograph of the upper left

central incisor was taken at the start of the treatment and after placement of the 0.019 ×

0.025-inch SS wire so root resorption could be assessed. There were no statistically

significant differences between archwire sequences A, B, or C for patient discomfort (P >

0.05) or root resorption (P = 0.58). The number of visits required to reach the working

archwire was greater for sequence B than for A (P = 0.012) but this could not be

explained by the increased number of archwires used in sequence B.


Factors influencing friction

1. Bracket material.

2. Archwire material

3. Archwire shape

4. Archwire size

5. Slot size

6. Bracket width

7. Bracket / archwire angulation

8. Surface roughness of the archwire or bracket

9. Ligature material

10. Force of ligation

11. Biological factors like saliva, plaque and acquired pellicle

12. Force from occlusion

Mechanics of tooth movement

MOMENT = FORCE x DISTANCE

1. With a removable appliance, the force (X) is applied at a distance (Y) from the centre of

rotation (CR) and results in a tipping movement or moment of XY.

2. With a fixed appliance, a counter-moment of XY can be applied which neutralises the

tipping moment. The resultant force acts through the CR and bodily movement of the

tooth occurs. This is the principle of passive torque force.

3. If the counter-moment is greater than XY, [for example (X + A)Y ] the tipping movement

is neutralised but in addition a moment is generated in the opposite direction (AY). The

CR moves a greater distance than the point of application and apical movement occurs.

This is the principle of active torque force.

Steps of edgewise appliance treatment

1. Alignment and leveling

2. Arch coordination

3. OB and OV closure

4. Space colures

5. Finishing


6. Retention

Pitts 6-5-4-6 approach

Tom Pitts has described an approach to the early stages of treatment which helps

structure the decisions necessary to optimize the effect of early treatment mechanics. This

approach is based on the use of passive self-ligation but it provides a useful structure for

any type of appliance system. This includes:

A. six decisions that should be made at the start of treatment

1. Bracket system and archwire progression

2. Torque selection

3. Tooth recontouring

4. Bracket position

5. Disarticulation strategy

6. Early elastics

B. Five aesthetic and five occlusal features which should be 'read' at each visit.

I. Five aesthetic features to check before Appointment 4

1. Incisor axial inclination

2. Canine and buccal segment axial inclination

3. Gingival display changes

4. Buccal corridors

5. Smile arc development

II. Five occlusal features to check before Appointment 4

1. Bracket height and alignment

2. Vertical levelling and overbite correction

3. Antero-posterior correction


4. Transverse development

5. Arch coordination and interdigitation

C. The fourth visit - photos, panoramic radiograph and repositioning

appointment.

1. About four weeks after placement of the 0.018' x 0.025' archwire, schedule a bracket

repositioning appointment with a new orthopantomogram {may not be necessary) and

some up to date digital photographs of the occlusion.

2. Use this appointment to review torque selection as well as first and second order

bracket position.

3. In addition, review need for further tooth reshaping. This represents the end of the

first stage of finishing.

D. Six aspects to focus on during finishing

1. Check CR=CO

2. Check full correction achieved

3. Check interdigitation and arch coordination

4. Final adjustment of tooth shape and size

5. Gingival shape adjustment

6. Finishing elastics required?

Methods to correct rotation

For anterior teeth

1. Steiner wedge

2. Elastomeric wedge

3. Elastomeric modules

4. Rotation pin as in Begg appliance

5. AW bend or Offset bonding

6. Reciprocal force

7. Rotation spring as in tip edgewise


For posterior teeth

1. Lingual cleats

2. Reciprocal force

3. HG, TPA,

Intraoral auxiliaries

1. Archwire stops

It should be placed in an interdental space anterior to where you want the tooth movement to

occur. Its uses are:

1. Maintaining the archwire in a symmetrical position

2. When bond second molars early on in treatment, turning down the archwire behind the

second molars can cause significant discomfort.

Types

1. Crimpable stops: length 2 mm , Inner lumen size, 016", 0.018" , 0.022"

2. Composite stops are preferred as they are more effective and cheaper than crimpable stops!

2. Archwire hooks

A. Chair side soldered Hooks

B. Presoldered archwires

C. Crimpable hook

3. Torquing auxiliaries

4. Uprighting springs,

5. Rotation springs,

6. Sidewinders

7. Transpalatal bars

8. Quadhelix

9. Lip bumper

The use of lip bumpers is described by Ten Hoeve (1985). Its uses are:

Molar distalization for correction of mild crowding,

Very narrow mandibular arches

Incisor proclination if the lip is hyperactive an resistant to proclination.

Deep bite correction by molar extrusion and allowing Incisor proclination


Molar uprighting

More stable result theoretically because of the slow soft tissue adaptation.

10. Lacebacks (see below)

11. Bendback

1. Used to prevent wire displacement,

2. Control arch length

3. Not used if COS aimed to reduced in non exo cases,

Management of distally inclined canine in deep overbite cases

When the canine is initially distally angulated, overbite control can be compromised and

center line displacement may result during the aligning and leveling phase of treatment.

These problems may be overcome (Khambay, 2006)

1. Sectional appliance, begin by aligning the slots in the buccal segments, including canines.

2. Partial bonding of anterior teeth to allow the canine to upright without proclining the

incisors

3. Partial engagement of the canine

4. Use lace-backs.

5. Control molar anchorage.

6. Use tip edge bracket on canine

7. Progress slowly and patiently.

8. By swapping the canine bracket.

9. The use of an alternative bracket system with less prescription inclination, for example,

the MBT

Customized precision prescription appliances

Customised precision prescription appliances or orthodontic treatment can be delivered by

either:

1. Customising or individualizing brackets

2. Customising the bracket-tooth surface composite/resin interface to the patient’s

tooth morphology and planned treatment needs

3. Customising the archwires

4. Using selected prescriptions to semi-customize the appliance

5. A combination of the above


6. Aligners

Several technologies have come together to allow increased customisation of appliances

to an individual patient’s requirements.

1. Digital imaging

Digital imaging of photographs and radiographs now makes it easy to transmit or upload

patient data to sites that are geographically distant. In addition, the advent of intra-oral

scanners promises the elimination of impression taking.

2. Computer modeling

Computer modelling, design and manufacturing programmers provide an unprecedented

ability to visualize, manipulate and test treatment outcomes. The end results from these

programmes can then be used to construct customized appliances and precision bracket

placement systems

3. Robotics

Robotics is now being introduced to carry out precision archwire fabrication for nickel

titanium, titanium molybdenum and stainless steel archwires.

4. High technology materials and manufacturing technique

Metal injection molding and nickel titanium archwires are two examples of high

technology materials and manufacturing technology which facilitate customized

appliances through high precision, economical use of materials and minimal finishing

requirements.

Advantages

1. The digital records eliminate the need for plaster models and the disadvantages of plaster

study models in relation to manufacture, storage and retrieval mean that the future of

traditional plaster models has to be in serious question.

2. Reduced bonding and set-up time

3. Reduced stress of bond-up:

4. Allows placement of brackets and appliances by less experienced personnel

5. Reduced treatment time

6. Reduced cost ;although the initial cost is higher, this may be recouped if less visits are

required and treatment times are shorter


fixed appliance by almuzian

Health & Medicine