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Complete Clinical Orthodontics: Treatment Mechanics: Part 1
Complete Clinical Orthodontics: Treatment Mechanics: Part 1
The concept
Treatment mechanics has always been
Educational aims and objectives
of tremendous interest for all practicing This article aims to introduce the CCO System for correcting malocclusions.
orthodontists. Since the beginning of the
Expected outcomes
specialty, orthodontists have looked for the
Correctly answering the questions on page 39, worth 2 hours of CE, will
best, fastest, more consistent, and easiest demonstrate the reader can:
way to achieve the orthodontic correction
for our patients. This continuous quest has Become familiarized with the basics of the CCO System and its various
stages and how it relates to the correction of malocclusions.
allowed emerging technologies to integrate,
although slowly sometimes, with everyday
practice until they become a routine. As a
consequence, new materials, improvement
in design of appliances, and innovative malocclusions. Relevant characteristics of
ideas repeatedly transform the way active SLB, a newly introduced prescription
orthodontics is practiced. It is important (CCO Rx) along with a review of the three
for the contemporary orthodontist to stages of treatment mechanics will be
be knowledgeable of current changes, discussed. Part 2 will focus on bracket
to gain the benefits of such innovation. placement, arch coordination, leveling the
Today, after the first decade of the 21st occlusal plane, and vertical problems. Part
Figure 1: Shows the ideal relationship between the center
century has already passed, orthodontic 3 will focus on anchorage management in of the slot, the center of the bracket base, and the refer-
fixed appliances have experienced an extraction cases. ence point (middle of the clinical crown occlusogingivally
along the facial long axis of the crown)
interesting blend between technologies
that have been around for decades such The evolution of the straight wire
as the straight wire appliance (SWA), self appliance
ligating brackets (SLB), and low deflection The SWA was developed and introduced by
heat-activated arch wires. This integration, Lawrence Andrews in 19701 with the idea
in my opinion, represents an improvement of having an orthodontic fixed appliance
that, when correctly applied, facilitates the that would enable the orthodontist to
practice of orthodontics. achieve the six keys of normal occlusion2
The main objective of this series in the vast majority of cases in an efficient
of three articles (parts 1, 2, and 3) is to and reliable fashion. Even though the
introduce the concepts of treatment SWA is 42 years old and has become
mechanics within the CCO System. Part the most common appliance concept
over the past three decades, a review of Figure 2: (A) Shows a clinical closed up of the In-Ovation
1 will review how the SWA integrates R bracket with a 0.020 x 0.020 BioForce. The active clip
with SLB to produce an appliance that, some of the original concepts on which already started pushing the wire into the slot, which will
the SWA was designed, and the evolution begin to express torque. (B) Shows a SEM photo of an In-
when combining with specific arch wires Ovation R bracket, (taken at the University of Pennsylvania
on a specific sequence, can help the it has gone through, are fundamental to as part of a research by the authors research group).
better understanding of the beauty of this Bracket features such as the design of the slot and the
orthodontist to correct different types of clip can be better appreciated
Figure 4: Shows a SEM photo of Figure 5: Highlight CCO Rx, Figure 6: Highlight CCO Rx, Figure 7: Highlight CCO Rx, tip Figure 8: Highlight CCO Rx,
an In-Ovation R bracket with a torque for the upper incisor torque for the lower incisor for the upper canine torque for the lower canine
019 x .025 ss wire, (taken at
the University of Pennsylvania as
part of a research by the authors
research group). The springing
active clip pushes the wire into
the slot providing full torque
expression on a .019 x .025
ss wire
an active clip and to achieve optimal tooth Tubes are passive attachments. Tubes are achieve optimal tooth position at the end
position at the end of treatment. The not able to transfer the values they have, of treatment, even before the appliance is
goal was to offset some of the problems specifically torque, even if large wires are removed.
commonly seen with previous Rx that were used14,15. Trouble correcting the curve of
meant to be used with traditional bracket Wilson of maxillary molars and excessive CCO Rx highlights
system. lingual crown torque of mandibular molars The CCO Rx works as one system from
are some of the problems commonly seen second molar to second molar. The
Rotational control by many orthodontists. Therefore, the CCO following are some of the highlight changes
The springing capability of the In-Ovation Rx has specific overcorrections for the that were introduced:
clip, as well as its quite long mesial-distal maxillary and mandibular first and second U1/U2: 12/10 of torque have been
span, facilitate the correction of all rotations molars to achieve proper molar control. selected. These values have been proven
within the stage of leveling and aligning. time after time to be optimal if full expression
Also, the active clip favors complete Incisor control of torque is achieved. Thanks to the active
engagement of the wire into the slot. This To achieve optimal torque of the maxillary clip, full expression can be achieved on a
means that if the wire is not fully engaged, and mandibular incisors is very important .019 x .025 ss wire. It is not necessary to
the clip will not close. This avoids leaving for both esthetics and function. It affects lip increase and/or overcorrect these values
small rotations uncorrected as the wire support, and consequently facial esthetics, (Figure 5).
sequence progresses. Therefore, the CCO as well as anterior coupling of the incisors,
Rx removed some of the overcorrection of and therefore, anterior guidance. For L1/L2: -6, 0, 0 of torque, tip, and offset
the offset found in previous Rxs. the maxillary incisors, to achieve optimal have been selected. A small lingual crown
torque is sometimes difficult due to the torque overcorrection has been shown
Full torque expression large amount of bone the roots must go to help keeping the incisors in an upright
The active clip of the In-Ovation brackets through, specifically in extraction cases as position in situations such as leveling and
provides full torque expression on a .019 well as class II, division II cases. aligning, class II correction, leveling deep
x .025 ss wire. The springing clip pushes The inclination of the mandibular curve of Spee, etc. 0 tip and 0offset
the wire into the slot (Figure 4). Gick, et incisors is critical for both function and makes all four lower incisors bracket to
al.,13 shows that on the In-Ovation brackets stability. Their position should be upright be interchangeable facilitating bracket
a .019 x .025 ss wire can express the onto the alveolar bone. Class III camouflage, inventory (Figure 6).
same amount of torque than a .021 x Class II mechanics, and deep curve of Spee
.025 ss wire. Therefore, some of the are specifically challenging regarding the U3: 10 of tip has been selected as the
overcorrections of torque implemented upright position of mandibular incisors over best of both worlds. The increased mesial
in previous Rxs to overcome the play the basal bone. The CCO Rx combines crown tip found in some Rx (13) has
between the slot of the bracket and a .019 proven values of torque for maxillary incisors shown undesired distal tip of the U3 root,
x .025 ss, do not apply when using the In- that can be fully expressed thanks to the frequently seen in X-rays. However, an
Ovation bracket, and therefore the CCO Rx active clip, with a lightly overcorrection for upright U3 (8 or less) could compromised
removed those overcorrections. the mandibular incisors to achieve optimal proper coupling with the L3 and could also
control in all kind of clinical situations. The decrease arch perimeter compromising
Molar control CCO Rx is conveniently and progressively proper class I molar and canine relationship
It is the interaction between the bracket expressed throughout the stages of (Figure 7).
and the wire that will transfer the values treatment mechanics by using specific arch
of tip, torque, and offset to the teeth. wires at each stage. The ultimate goal is to L3: -8 of torque: In many cases where
Figures 12A-12B: Diagrams A and B show how round wires will allow molars and premolars to level, align,
and upright, which will produce a lasso effect on the incisors. This will upright and sometimes even retract
the protruded incisors
canines, which will increase the anchorage overjet. In an ideal intercuspation of a Class position of the mandible in centric relation,
in the front part of the arch facilitating the I, one-tooth to two-teeth occlusal scheme, and relationship of the upper/lower incisors
loss of anchorage in the posterior part of the palatal cusps of the maxillary molars with the lips. Arch space management is
the arch. This is critical in cases where the should intercuspate with the fossae and important to understand because the SWA
treatment plan calls for maximum retraction marginal ridges of mandibular molars; the tends to flatten the curve of Spee, which
of the maxillary and/or mandibular incisors. buccal cusp of the mandibular premolars requires space in the arch. If not enough
Then, round wires will allow the molar and should intercuspate with the marginal space is available or created, the incisors
premolars to level, align, and upright, which ridges of the maxillary premolars; and the will procline, increasing the arch perimeter.
will produce a lasso effect on the incisors mandibular canines and incisors should This incisor proclination will also decrease
that will upright and sometimes even intercuspate with marginal ridges of the the overbite and may help, if it only occurs
retract (Figures 12A and 12B). The 0.020 maxillary canines and incisors. If this in the lower arch, to decrease the overjet.
x 0.020 BioForce will make the clip of the occlusal scheme occurs, it will then provide Flattening the maxillary and mandibular
SLB active and thus start delivering torque; an overjet of 2 to 3 mm all around the occlusal planes, proclining the incisors,
nonetheless, its strength is not sufficient arch from second molar to second molar. can be of help in deep bite cases. When
to compromise the anchorage that has Then, the maxillary arch wire must be 2 the incisors are not allowed to procline,
already been created with the round wires. to 3 mm wider than the mandibular arch space in the arch must be created.
Usually, after 8 to 10 weeks with the 0.020 wire. The arch wire coordination is done This is specifically important to avoid
x 0.020 BioForce, the stage 1 of leveling with the stainless steel wire. Even if they periodontal problems in cases with thin
and aligning is finished, and it is the first come preformed, the clinician should not bone surrounding the incisor area. Up to 4
time to evaluate bracket placement and rely on this, and should check them before to 6 mm can be created with interproximal
debond/rebond as necessary. Then, the insertion (Figure 13). Another important reduction of teeth, usually done on the
patient is ready to start stage 2, the working aspect of arch coordination is the effect incisors and, less often, the canines and
stage. Table 1 shows the most common that it has on the vertical dimension and premolars. If more than 6 mm of space is
wire sequence for this stage of treatment. the sagittal dimension. This specific issue required, extraction of premolars could be
will be reviewed in detail in part 2. indicated.
Stage 2: Working stage Another important factor to consider
At this stage, the maxillary and mandibular Overbite and overjet correction when evaluating overbite/overjet
arches are coordinated, proper overbite An optimal overbite/overjet relationship problems is the position of the mandible.
and overjet are achieved, Class II or Class does not have to be a certain predetermined Often, differences between a maximum
III are corrected, maxillary and mandibular number of millimeters. More important is intercuspation (MIC) and centric relation
midlines are aligned, extraction spaces the functional relationship they have. This (CR) can produce significant differences
are closed, and maxillary and mandibular means that the overbite/overjet should in the overbite/overjet relationship. And
occlusal planes are paralleled. Although be compatible with a mutually protected last, but by no means the least important,
most of these corrections happen occlusal scheme, and thus, allow for a is the sagittal and vertical relationship of
simultaneously, some important points proper anterior guidance in protrusion and the maxillary and mandibular incisors with
must be emphasized regarding arch lateral excursive movements. Although, as the lips. In an open bite case, should the
coordination, management of the overbite/ mentioned earlier, the number of millimeters orthodontist intrude the molars or extrude
overjet, and the use of intermaxillary is less important than the function, it is found the incisors? In a deep bite case, should
elastics. that an optimal overbite is usually around 4 the clinician intrude the maxillary incisors,
mm, and an optimal overjet is 2 to 3 mm. the lower, or both? These basic but very
Arch coordination When diagnosing and treatment planning important questions can be answered
The maxillary and mandibular arch wires overbite/overjet problems, it is important through an understanding of the optimal
must be coordinated in order to obtain a to take the following key points into relationship of the incisors with the lips.
stable occlusal intercuspation and proper consideration: arch space management, According to contemporary esthetic
A 12-year, 6-month-old Caucasian female consulted for orthodontic treatment due to a crossbite of the upper-right canine. Patient presented with a Class I
malocclusion in late mixed dentition. Upper-right canine and upper-left lateral incisor were in crossbite. Midlines were off.
Composite 3: Mid course of the stage 1, leveling an aligning. Upper and lower .018 Sentalloy wires. The bite was temporarily open with composite buildup
on the lower first molar to allow the canine to move buccaly into alignment
Composite 4: Upper .020 x .020 BioForce wire to finish leveling upper arch
Composite 5: Upper and lower .019 x .025 SS coordinated arch wires. Notice parallelism of the upper and lower occlusal planes
Composite 6: Upper and lower .021 x .025 braided arch wires. At this time, triangular short vertical elastics are used to achieve optimal intercuspation
trends and taking into account the aging correct crossbites lar occlusal planes are parallel and all the
process, for adolescents and young adults, For an extended period of time. bracket slots are aligned, bracket position
maxillary incisors should have, at rest, an I usually use intermaxillary elastics in should be carefully checked for minor cor-
exposure of about 4 mm beyond the the following situations: rection of tooth position, and therefore the
most inferior point of the upper lip known At the working and finishing stages second time of debond/rebond should be
as upper stomion. As explained earlier, On square or rectangular stainless steel done. The last wire to be used is a stainless
an optimal functional overbite should be wires steel multibraided 0.021 x 0.025 arch
about 4 mm. Now, if we put together the On the buccal side of the mouth, short wire. Although this wire is large enough to
last two concepts, the incisal edge of the class II or III and/or triangular verticals fill the slot of the bracket and then maintain
lower incisors should be at the same level The three types of intermaxillary the tip, torque, and offset of each tooth, its
with the most inferior point of the upper elastics this author commonly uses are resilience permits both minor bracket repo-
lip. Therefore, any vertical change of the 3/16 4 oz., 6 oz., and 8 oz. elastics. Short sitioning and settling of the occlusion into
incisors will affect not only the function means, in a Class II, for instance, from the an optimal intercuspation. It is important
through changes of the anterior guidance, maxillary canine to the mandibular second to notice that at this point in treatment, all
but also the esthetics through the premolar in a non-extraction case and to the appliance interferences should be re-
amount of tooth exposure. These anterior the first mandibular molar in an extraction moved using a finishing carbide bur on a
functional/esthetic references can help the case. high-speed handpiece. With a thin articular
clinician to determine the best strategies Table 2 shows the most common paper, all contacts must be checked. Only
to correct overbite/overjet problems and wire sequence for non-extraction cases, at tooth-tooth contacts should be allowed. All
will be of special importance for planning this stage of treatment. Wire sequence for brackets, tubes, or band contacts must be
cases involving orthognathic surgery. extraction cases will be specifically covered removed to allow proper settling. Vertical
in part 3). triangular 3/16 elastics, either 6 oz. or 8
Intermaxillary elastics oz., are used to achieve proper intercuspa-
Discretion is a good word to describe the Stage 3: Finishing stage tion. These vertical elastics should not be
use of intermaxillary elastics. I use them and As I discussed previously, the active clip used with the braided wire for more than 6
like them, but it is important to understand of the In-Ovation bracket system, pushes, weeks to avoid rolling premolars and mo-
how they are used to avoid problems. I and sits the wire onto the slot achieving lars lingually, which can be detected not
usually do not use intermaxillary elastics in optimal bracket expression with a 0.019 x from the buccal but rather from the lingual,
the following situations: 0.025 stainless wire. This is especially true where premolars and/or molars will not be
Round wires in non-extraction cases with an average contacting. Finally, before removing the ap-
Initial leveling and aligning, low-deflection curve of Spee. However, in some cases pliance, a complete assessment of the oc-
wires the size and stiffness of a 0.021 x 0.025 clusal end of treatment goals should be
To a terminal tooth, last tooth in the arch stainless steel is indicated, such as in cas- performed. Table 3 shows the most com-
In the anterior part of the mouth to close es with a deep curve of Spee and extrac- mon wire sequence for this stage of treat-
open bites tion cases where minimum anchorage is ment. OP
In the posterior part of the mouth to required. Once the maxillary and mandibu-
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