CLINICAL

Maintaining clearly defined treatment objectives:

part 1

Drs. Domingo Martin and Jorge Ayala demonstrate how to achieve perfect functional and esthetic
outcomes using the FACE Evolution bracket prescription

I n today’s orthodontic treatment of pa-

tients, the outcomes should no longer
simply focus on creating a beautiful smile
by correcting the malocclusion. Regardless
of the patient’s age, the goal should be the
best possible alignment of the teeth to en-
able their integration into a system of cor-
rectly positioned joints, efficient masticatory
function, promotion of a healthy state of the
tooth surrounding tissue, appropriate coor-
dination of the lips, as well as ideal facial
balance. Clinicians can achieve this with a
thorough and complete diagnosis that ac-
counts for not only the teeth but also the
joints, a stable condylar position, facial
esthetics, and optimal muscle function. In
many instances, that cannot be achieved
with orthodontics alone; and therefore,
close cooperation is necessary between the
orthodontist, and the treating dentist and/or
colleagues from other specialties.
FACE (Functional and Cosmetic
Excellence)
Some time ago, Dr. Ronald H. Roth initi-
ated a treatment philosophy based on a
comprehensive orthodontic diagnostic and
treatment system. The philosophy embraces
the objective evaluation and diagnosis of the
jaw position as well as functional occlusion
and implementation of treatment based
on this diagnostic information. Based on
Roth’s basic principles, which were initially
advanced further by the Roth Williams Inter-
national Society of Orthodontists (RWISO)
Figure 1: The four steps of the FACE treatment philosophy
and later by the RW FACE Initiative (Roth
Williams Functional and Cosmetic Excel-
lence) and today’s FACE Group (Functional
and Cosmetic Excellence), respectively, the
focus is on the clinical objective: a functionally
and esthetically perfect treatment outcome.
State-of-the-art technology permits even
more accurate diagnosis, treatment plan-
ning, and treatment.
Treatment philosophy
The FACE treatment philosophy harmo-
nizes facial and dental esthetics, periodontal
health, functional occlusion with an ortho-
pedic stable joint position, open airway, and
stable results. It relies on clearly defined treat-
ment objectives, which are summarized in
the following four steps (Figure 1).
Step 1: proper joint function
(form of joints; centric occlusion = centric
relation [CO=CR])
Clinicians should first check for a stable
orthopedic position of the joints, which
allows for correct diagnosis and treatment
planning.
Step 2: functional occlusion
(form of occluded dentition)
The posterior teeth should have correct
three-dimensional positions so that the
mandible stays in a stable position. Addi-
tionally, the occlusion should have a correct
vertical dimension.
Step 3: anterior guidance
(form of tooth, vertical and horizontal overbite)
The anterior teeth (from canine to canine)
should have three-dimensionally correct
positions that maximize good function and
esthetics.
Step 4: facial esthetics
(ideal proportions)
Realization of steps 1 to 3 finally leads
to step 4, the facial esthetics, whereby the
final treatment represents the best possible
combination of esthetics, function, and a
stable orthopedic mandibular position.

Key factors
Dr. Domingo Martin has a BA from the University of Southern California and an MD and DDS from the University of Over the years, the FACE Group has
the Basque Country in Spain. He also earned a Master in Orthodontics from the University of Valencia in Spain. He
is the Director of the FACE/Roth Williams Center for Functional Occlusion for Europe and has postgraduate work in accumulated extensive clinical experience
Bioesthetic Dentistry from the OBI Foundation for Bioesthetic Dentistry. Dr. Martin gives courses and conferences based on numerous studies. This allows defi-
all over the world, and he has a private practice limited to orthodontics in San Sebastián, Spain. He is also a FACE nition of those key factors within the frame-
Member.
work of the FACE treatment philosophy that
Dr. Jorge Ayala has a medical degree from the University of Chile with a specialty in Orthodontics and Maxillary Orthopedics from are crucial for achieving perfect functional
the University of Chile. He is Director of the FACE/Roth Williams Center for Functional Occlusion from Latinoamérica and a professor and esthetic treatment results.
of the FACE/Roth Williams Center for Functional Occlusion in California. He runs a private practice limited to orthodontics in Santiago
de Chile. He is the author of numerous articles and publications and speaker at national and international courses and conferences.
Facial esthetics
Disclosure: Dr. Martin is a consultant for Forestadent. Which tooth movements benefit the
facial esthetics of a patient, and which

24 Orthodontic practice Volume 7 Number 5


movements tend to have a negative effect
on facial esthetics? Bearing optimal facial
esthetics in mind, as professionals, we are
able to determine not only the ideal position
of maxilla and mandible, but also the exact
position and torque of the teeth. We also
can determine the treatment cephalometric
measurements necessary and implement
them accordingly.
For example, we know that counter-
clockwise rotation of the mandible moves the
mandible and chin forward and shortens the
lower facial height, thus allowing improved
facial esthetics. We also know that facial
asymmetry closely relates to the status of
the joint, the occlusal function, as well as
the alignment of the teeth. Clinicians need
to consider this.
Dental esthetics
Many factors determine dental esthetics.
For example, the individually correct propor-
tions of crown length and crown width of the
anterior teeth have importance. If dispropor-
tion occurs between length and width — i.e.,
too square or too long — teeth will distort the
esthetic impression. The length and shape
of the premolars and molars also affect
esthetics. For example, the mesial buccal
cusps of the first maxillary molars should
be more prominent in the dental arch of the
maxilla than the second molars, as exempli-
fied by the Roth arch shape.
Clinicians should also consider gingival
esthetics and the gingival margins, for
example, when deciding about vertical tooth
movement or intrusion of the anterior teeth.
When the lips are at rest position, approxi-
mately 3 mm to 4 mm of the incisors should
show. Also, the incisors should converge
mesially to the midline and incline labially.
Dental and facial esthetics form a close
relationship. The dental midlines of the
maxilla and mandible should therefore largely
correspond to the facial midline. For good
esthetics, the upper lip should be at the
level of the gingival margin when the patient
smiles. In contrast, 2 mm to 3 mm of visible
gingiva would present a perfect full smile.
The position of the occlusal plane also has
importance, and this should lie parallel to the
interpupillary plane.
Functional occlusion
Peter E. Dawson,1 Jeffrey P. Okeson,2
and many others have described the impor-
tant role of the temporomandibular joints in
establishing functional occlusion. Roth also
recognized the significance of the joints and
pointed out that any changes to the joints
Volume 7 Number 5 Orthodontic practice 25
The FACE treatment philosophy harmonizes facial and
dental esthetics, periodontal health, functional occlusion
with an orthopedic stable joint position, open airway,
and stable results.
would have a direct effect on the occlusal
relationship of the teeth. He also regarded
the condylar shift as a major contributing
factor to unstable treatment outcomes.
Okeson suggests that “an orthopedic
stable joint position (orthopedic stability)
exists when the stable intercuspal position
of the teeth has harmony with the musculo-
skeletally stable position of the condyles in
the fossa. When this position exists, func-
tional forces can apply to the teeth and joints
without injury.”3 However, if this harmony
does not exist, Okeson applies the term
orthopedic instability with overload and injury,
such as tooth wear, periodontal changes,
and TMJ alterations as the consequences.4
Instead of using the term centric relation
(CR), we should therefore better focus on the
orthopedic stable joint position.
Periodontal tissues
Stable results can occur only if healthy
tissue surrounds the teeth. Clinicians should
follow some important rules — e.g., ensuring
adequate attachment of keratinized gingiva
prior to any orthodontic tooth movement to
avoid recession of the gingiva.5 Epithelial
attachment, connective tissue, alveolar crest,
and CEJ should also harmonize.
The apices of the teeth should be centered
within the alveolus to avoid fenestrations,
gingival recessions, and root resorption.
Ideally, the teeth should be positioned
at the interproximal bone height and in such
a manner that the forces can be guided
adequately and without distracting inter-
ference and deviation. It is also important
to provide the best possible conditions for
performing oral hygiene — i.e., correct inter-
proximal contacts with as little crowding as
possible, appropriate axial positioning of the
teeth, and correction of vertical bone defects.
Airway
By using cone beam imaging, we can
analyze the airway volume of our patients
CLINICAL
and detect possible alterations or blockage
of the upper airway tract at an early stage.
Additionally, the CBCT images provide
important information on possible compli-
cations in the maxillary sinus.
Stability
Regarding the stability of orthodontic
treatments, numerous studies examine the
factors that can contribute to stability, and
others promote non-stability. However, no
studies have yet related stability to occlu-
sion; still, in our experience, stable joint
positions and harmony between the teeth
and condylar positions play important roles
in stability. When this condition exists, the
mandible can open and close on a closure
arc without posterior interferences, and
no mandibular deflection. Stability also
depends on bilateral protected occlusion
as well as uniform contact on the central
cusps with forces acting on the long axes
of the teeth.
FACE Evolution bracket prescription
Since the introduction of the straight-wire
appliance in 1970 by Lawrence F. Andrews,
several prescriptions have arisen that modify
some torque, angulation, and rotational
values; however, they basically maintain
many of Andrews’ original prescription. Even
so, these modifications try to resolve prob-
lems in orthodontic biomechanics. Recent
developments reveal that variable prescrip-
tions continue to gain favor in their ability to
treat a variety of malocclusions.
Technical progress of the past years has
opened up new opportunities in diagnos-
tics and treatment planning. Thus, scientific
studies using the cone beam computed
tomography (CBCT) have shown a significant
percentage of patients present with dehis-
cences and fenestration.
Additionally, evaluations using CBCT
during the final stages of treatment reveal a
disturbing rate of roots outside the bone in
CLINICAL

Figures 2A–2D: 2A-2B. Tomography that reveals the radicular position of the maxillary premolars 2 months after inserting a .019” x .025” stainless steel archwire in a bracket with
torque –7°; 2C-2D. The radicular position of the upper canines with straight arch brackets with –2° torque, 2 months after inserting a stainless steel archwire of the same dimension

different sectors of both jaws (Figures 2A-2B).

These disturbing observations give us cause
to critically question negative torque used in
most prescriptions.
We have recently determined the value
of a bracket system that brings us closer
to the aim of a functional and esthetic ideal
treatment outcome — the FACE Evolution
bracket prescription*.
We admire the contribution made by
Andrews as one of the most important
advances for orthodontics, and everything
indicates that the values obtained from his
sample of normal non-orthodontic patients do Figures 3A-3B: Difference between the information supplied in regard to bone by Orthopantomography (3A) and CBCT (3B)
not apply to all orthodontic patients, especially
those presenting poor apical bases and/or
thin periodontium, which is quite common.
We hypothesize that the individuals
studied by Andrews had ideal occlusions,
probably because of their correct basal and
alveolar development, which differs from that
of most patients. When Andrews performed
his research, none of the sophisticated
instrumentarium we can now use existed.

Modification of torque
Extensive clinical research has enabled
us to tackle and resolve problems revealed
on CBCT. Previously, we could not observe
the thickness of the vestibular and lingual
alveolar bone (Figures 3A-3B); CBCT exami-
Figures 4A-4B: Tomography revealing a common situation with canines: a very poor or no vestibular bone, which contra-
nations revealed the mesial and distal bone
indicates any kind of negative torque
levels of the dental roots, and we commonly
see that the vestibular or lingual alveolar bone
limits some tooth movements.
Quite commonly, mandibular incisors
and maxillary and mandibular canines have
compromised alveolar bone.

Torque in the canines

Canines often have thin bone on the
labial and appreciably thicker bone on the
palatal surfaces. Several patients have such
prominent canine radicular prominences that
require unusual treatment plans. Figures 5A-5B: 5A. Clinical picture that clearly shows the radicular prominence and especially delicate periodontal situation
On these occasions, the CBCT reveals a in the maxillary canines. 5B. After using a .019" x .025" rectangular archwire with brackets of torque –2° in the maxillary
thin layer of vestibular cortical bone, and in canines, the radicular problem was increased

26 Orthodontic practice Volume 7 Number 5


some cases, bone fenestration that contra-
indicates any radicular vestibular movement
(Figures 4A-4B, 5A-5B). This common situ-
ation caused us to modify torque values –2°
to +3° for maxillary canines and from –11°
to –6° for mandibular canines.
Extreme radicular prominence requires a
bracket with a 20° torque for maxillary and
mandibular canines. This bracket quickly
moves the canine root into the thick lingual
cancellous bone. This excessive torque
barely leads to sufficient movement, as its
Figures 6A-6B: 6A. Orthopantomography and CBCT. 6B. The CBCT images show the bone limitations for movement of the incisors
Figures 7-7B: 7A. Picture of a tube of a known brand that reveals the features of the slot and the lack of rectangular form
of a .019” x .025” steel archwire. Obvious explanation of the lack of efficiency to produce torque. 7B. FORESTADENT tube
effect is greater on the crown than the root, in
patients with fenestrated roots. This enables
us to attain bone re-coating of the alveolar
defect. Once we obtain the needed effect,
we switch the working bracket to a standard
prescription bracket (+3°) or (–6°).
Torque in the lower incisors
For the mandibular incisors, FACE
Evolution has brackets with torque –1° and
–6° and can transform into +6° by merely
inverting the bracket by –6°. Theoretically, a
CLINICAL
+6° torqued bracket for mandibular incisors
ideally compensates Class II malocclusions
to give correct position anterior anchorage.
The truth is the available alveolar bone will
determine the bracket chosen.
The FACE Evolution bracket chosen
depends on available bone, teeth in inclina-
tion, and the type of movement needed.
Torque in the molars
Maxillar molar tubes have required modi-
fication. Orthodontists concerned about
functional occlusion know that premature
contacts in the second molars are common.
Positive molar torque frequently causes
“hanging” palatal cusps, which interfere with
mandibular closure and often lead to lateral
interferences. The problem often forces us to
use transpalatal bars and/or torsion bends
in the archwires.
Clinicians need to remember that manu-
facturing tolerances commonly give us over-
sized brackets and tubes and undersized
wires, which manifests as inefficiencies. One
of the causes of this inefficiency is the play
presented by the arches in the lumen of the
tubes. Several studies have demonstrated
that this play is because of a slight oversizing
of the slots of the brackets and play of the
tubes, and also the fact that the arches are
slightly smaller than stated by manufacturers
and often even have rounded edges. Tests
performed with tubes from several compa-
nies reveal to us angles of torque loss of up
to 26° with .019" x .025" steel archwires
and up to 11° with .021" x .025" archwires
(Figure 7A).
The FACE Evolution system has devel-
oped maxillary molar tubes. A negative
torque of –30° has been introduced into the

Figures 8A–8C: 8A. Tomography that reveals this clinical situation in a second left maxillary molar, in this case with an appropriate bone for correction of the torque (V = vestibular). 8B.
Tomography revealing the radicular situation to consider during correction of the torque (V = vestibular). 8C. Common situation especially in the maxillary second molars with positive torque,
which leads not only to increased occlusal vertical dimension but also to interference with centric and eccentric mandibular movements

Volume 7 Number 5 Orthodontic practice 27

CLINICAL

maxillary molar tubes. This compensates

for the poor fit of the wire to the tube. Still,
doctors must take special care regarding
available bone since some cases could
contraindicate any kind of movement.
The aim of this modification is not to
attain a torque of –30°, but rather a way of
compensating the torque loss of the arches
in the tubes.
To summarize, the differences in torque
in regard to Roth’s prescription are found in
the maxillary and mandibular canines and the
upper molars. The alternative for the mandib-
ular incisor of –6° and +6° is also added.
Rotations
One attribute of the Roth prescription
is the excellent anchorage obtained by the
distal rotation produced in the maxillary and
mandibular molars. However, this feature, so
useful for retrusion of the anterior teeth, turns
into a hindrance in two situations: the first, in
patients requiring minimal anchorage, espe-
cially in the mandibular jaw; the second, when
obtaining suitable finishing, and the molar rota-
tion does not enable correct intercuspation
and coordination of the antagonist molars.
Indeed, virtually 100% of patients
treated with this prescription, analyzed in
Figures 9A-9B: Models that reveal the before and after the correction of torque for the 7s
centric relation, present interference with the
closure. This is especially true of the second
molars, which Roth’s philosophy resolves,
once the appliances are withdrawn, by using
a gnathologic positioner.
This situation occurs because of the
loss of alignment of the mesiodistal occlusal
groove of both the maxillary and mandibular
first and second molars (Figure 10B). The
reason for this loss of alignment is found in
the distal rotation of 14° in the first molars,
which has the consequence of an antago-
nistic reciprocal effect in the second molars
as they displace toward the vestibule region.
This undesired movement occurs when
applying positive rotations above 10°, which
ordinary prescriptions have. To solve this
problem, we use 10° rotation in the maxil-
lary molars and 0° rotation in the mandibular
molars. This enables perfect finishing in most
cases and simultaneously facilitates space
closure patients needing minimal or medium
anchorage.
In the next article, we will look at one
of the most interesting aspects of the new
prescription: a bracket that serves not
only during the working phase, but at the
same time, takes into account the finishing
phase. Another feature introduces the
hybrid possibility — i.e., active in the ante-
rior brackets and passive in the posterior
brackets. Last but not least, the working
tubes and working brackets compensate
for lack of torque in some cases and reduc-
tion of torque in other cases. To finish we
will show a variety of patient therapies
where the prescription was used and how
of our goals were achieved. OP
* Fa. FORESTADENT

Figures 10A-10B: Occlusal photo that presents correct alignment of the mesiodistal sulci of the molars and premolars, a fundamental aspect to attain correct occlusion. 10A. The tubes used
have a distal rotation of +10°. 10B. Occlusal photo that reveals the misalignment of the marginal ridges of the first and second maxillary molars, with tubes of +14° distal rotation

REFERENCES
1. Dawson PE. Functional harmony. In: Dawson PE. Functional Occlusion: From TMJ to Smile
Design. St. Louis, MO: Mosby; 2007.
2. Okeson JP. Criteria for optimal functional occlusion. In: Okeson JP, ed. Management of
Temporomandibular Disorders and Occlusion. 5th ed. St. Louis, MO: Mosby; 2003.
3. Okeson JP. General considerations in occlusal therapy. In: Okeson JP, ed. Management of
Temporomandibular Disorders and Occlusion. 5th ed. St. Louis, MO: Mosby; 2003.
4. Okeson JP. Criteria for optimal functional occlusion. In: Okeson JP, ed. Management of
Temporomandibular Disorders and Occlusion. 5th ed. St. Louis, MO: Mosby; 2003.
5. Roth RH. The Roth functional occlusion approach to orthodontics. Notes from lecture intro-
ducing the functional occlusion section of the Roth/Williams Center for Functional Occlusion
2-year program.
6. Andrews L.A. Straight Wire: The Concept and Appliance. San Diego, CA: LA Wells; 1989.
7. Roth RH. The maintenance system and occlusal dynamics. Dent Clin North Am.
1976;20(4):761-788.
8. Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby; 2007.
9. Lee RL. Esthetics and its relationship to function. In: Rufenacht C. ed. Fundamentals of
Esthetics. Carol Stream, IL: Quintessence; 1990.
10. McNeill C. Fundamental treatment goals. In McNeill C, ed. Science and Practice of Occlusion.
Carol Stream, IL: Quintessence; 1997.
11. Spear FM. Fundamental occlusal therapy considerations. In: McNeill C, ed. Science and
Practice of Occlusion. Carol Stream, Quintessence, IL; 1997.
12. Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby; 2007.
13. Melsen B, Allais DA. Factors of importance for the development of dehiscences during labial
movement of mandibular incisors: a retrospective study of adult orthodontic patients. Am J
Orthod Dentofacial Orthop. 2005;127(5):552-561.

28 Orthodontic practice Volume 7 Number 5