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The Edgewise Slot: Angle's Orthodontic Albatross

Peter C. Kesling, DDS, ScD, Private Practice of Orthodontics, Westville, Indiana, USA.

Editor's Note: This provocative article makes us question just how important it is to
perpetuate time-linked contributions that were avant garde 75 years ago. Even with myriad
alterations in original design, attempting to improve the edgewise bracket after it was
introduced by Edward H. Angle 75 years ago as "the latest and best," is it what we want as
we enter the new millennium? As we know more about biomechanics and appreciate the
need for an efficient force that does not have iatrogenic consequences, can we move teeth
faster, more easily, and more safely? Great credit must be given to EHA, the mechanical
genius, and to those predecessors who developed orthodontic brackets (see Hanks S.
Trying to get out of the 20th century. WJO 2000;1:9–16). But would those same leaders
produce the same mechanisms today, knowing what we do now, particularly about
bioengineering, tissue response to orthodontic forces, and the relationship of force
magnitude and treatment time to iatrogenic sequelae? Does the proverbial Procrustean bed
wire-and-bracket armamentaria answer all treatment challenges? Don't we need to do more
than "straighten teeth"? Your comments are welcomed by the author, as well as the WJO,
for "Letters to the Editor" in subsequent issues. --T.M. Graber

References:
In 1798, Samuel Taylor Coleridge published his classic poem, "The Rime of the Ancient
Mariner." As a symbol of the Mariner's guilt for killing an albatross and causing a change in
the weather, Coleridge had the Mariner's shipmates hang the dead sea bird around his
neck:

Ah! Well-a-day! What evil looks

Had I from old and young!
Instead of the cross, the Albatross
About my neck was hung.1

In 1925, Edward H. Angle unintentionally placed an albatross around the necks of

orthodontists--the edgewise archwire slot. However, instead of hanging for a mere 32
stanzas, it has remained for 75 years. The problem was (and still is) that the archwire slot
prevents free mesial or distal crown tipping, which severely restricts anteroposterior
movements in the buccal segments. Since the teeth are not free to tip, increased levels of
force are required for retraction, space closing, and even anterior bite opening. This, in turn,
often necessitates extraoral force to gain anchorage or achieve desired tooth movement.

Yet, Angle felt this feature was one of the great advantages of the edgewise mechanism:
"And quite as important…though seeming as yet to be little appreciated, there must be
established fully normal upright axial positions and relations of the teeth…"2

However, these normal, upright positions are imposed early and held throughout treatment.
This, in effect, turns the very teeth to be moved into anchor teeth. As a means of promoting
retraction to correct Class II or III relationships, Angle suggested second-order bends in the
archwire. However, in the absence of extraoral force and/or intermaxillary elastics, these
bends can just as easily move roots mesially as crowns distally. Angle evidently died without
realizing the enormity of the problem. His wife, Anna, related that one of his last statements
was, "My work is done."

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Fig 1 (a) Angle's first appliance intended to retract a

canine distally. Faulty design set up anchorage in the
canine and permitted rotation of the second molar.
(From Angle.3 ) (b) Corrected design permitted distal
tipping of the canine and provided anchorage from
both the second premolar and first molar. (From
Angle. 2 ) (c) Buccal view of Angle's perfected traction
screw. Note: Dotted lines indicate Angle's perception
that heavy forces caused the canine to tip about a
fulcrum near the gingival crest and the molar to move
bodily. (From Angle.4)

ANGLE'S FIRST APPLIANCE ALSO MECHANICALLY FLAWED

Ironically, both Angle's first and last published appliances had similar flaws--
neither facilitated the retraction of teeth to close spaces or correct anteroposterior
discrepancies. The first appliance, presented in 1887 (Irregularities of the teeth,
presented before the Ninth International Medical Congress, Washington DC,
USA), was intended to retract a canine distally into a first premolar extraction site
(Fig 1a). However, careful analysis of the mechanics involved, followed by
analysis of the application of force and subsequent tooth responses, reveals that
the second molar, which was intended to offer resistance to the traction force, was
free to rotate distobuccally. The tube on the canine, being horizontal, set up
anchorage in the very tooth to be moved. Angle would later refer to such teeth as
being stationary anchorage.

The following year, Angle corrected the mechanical errors at both ends of his
traction force in an article with a title giving an indication of this 32-year-old's
growing sense of confidence: "New System of Regulation and Retention." 3

In his revised appliance (Fig 1b), the second premolar and the first permanent
molar were transformed into a stationary anchorage unit by soldering a horizontal
tube onto bands around both teeth. The canine crown was permitted to tip distally
by placing a tube horizontally on its mesial surface. Angle would later refer to such
tipping movement as "simple anchorage."

The importance of this new arrangement--tipping of the tooth to be moved and

bodily movement of the resistance teeth--was stressed by Angle in his sixth
edition,4 published 10 years later, by an illustration (Fig 1c) that appeared 4 times
along with the following words: "Be it remembered that the tube attached to the
cuspid band must always stand at right angles to the long axis of the tooth, that a
free hinge-like movement of the tooth in retraction may be gained...."

The only before-and -after treatment records of an extraction case in this text are
those of a patient treated with such traction screws (Fig 2). It can be seen from the

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pretreatment inclinations of the maxillary anterior teeth that Angle chose this case
carefully. The corrections shown were accomplished by distal and lingual crown
tipping only. There was no need for subsequent root uprighting. He claimed it was
unnecessary to show the treatment results of other patients because they would
all look the same. However, he did lament the fact that by extracting in one arch
and not the other he was substituting one malocclusion for another.

CHALLENGE BY CALVIN CASE

Several years before, another prominent orthodontist, Calvin S. Case, had

invented and promoted appliances that could tip crowns, "force the roots," or
move teeth bodily.5 Upper and lower arch bars with threaded ends were loosely
connected to the ends of vertical bars soldered to bands on the anterior teeth (Fig
3).

Therefore, Case had an extremely capable, although cumbersome and potentially

powerful, new appliance to both tip and upright teeth. He later termed this his
"Contouring Apparatus," because he felt that when maxillary roots were moved
forward and laterally more than their crowns, the middle features of the face
achieved a fuller contour.

Fig 2 Angle's treatment of a maxillary first premolar extraction case by 2 traction screws, a labial
arch, elastic bands, and occipital anchorage. Bone was also removed palatally to the central incisors
to lessen treatment time. Casts below indicate that correction was made by tipping only. Top right
photo shows patient profile after treatment. Photo top left (reversed and repositioned to facilitate
comparison) shows the difference this treatment can make in profiles. However, careful reading of
the text and comparison of facial features reveals these photos, associated with the only records of
before-and-after treatment in the sixth edition of Angle's text, 4 are not of the same individual.

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Fig 3 (a) Contouring appliance to "bodily" protrude root tip. Power bow (P) is activated by tightening
the nut mesial to its sheath. Fulcrum bar (F) provides traction by tightening the nut at its end. (b)
Apparatus for retracting the root and moving the incisal edge forward. Both bars are activated by
tightening the nuts against their respective sheaths. Designs of both appliances permit movement by
the power bars without adjusting the nuts on the fulcrum bars. By placing the nuts of both the upper
and lower arch bars on the same ends of the buccal sheaths, teeth can be moved bodily--labially or
lingually. (From Case. 6)

Fig 4 Before and after facial masks and dental casts of 4 first premolar extraction treatment by Case.
Through the use of power bars, the teeth have been bodily repositioned, although by force levels that
are today mainly relegated to rapid maxillary expansion devices. (From Case.6 )

During retraction of the 6 maxillary anterior teeth, Case observed mesial slippage
of the anchor teeth. This loss of anchorage seemed of no concern to him--rather,
it helped prove the amount of force his appliance could generate. To him, it
seemed to be a positive feature. The quality and degree of dental and facial
changes Case was able to produce in the early 1900s are shown in one of the
cases published in his 1908 text (Fig 4).6

Case pointed out that when an uncontrolled tooth was tipped from a heavy force,

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such as that delivered by a traction screw, the root apex tended to travel in the
opposite direction. He observed that the fulcrum for this action was often near the
gingival crest. However, he felt that if a light, continuous force could be applied to
one end of a tooth, resorption would tend to occur all along one side of the root.
There would be little tendency for a fulcrum to cause the other end of the tooth to
move in the opposite direction. He later captured both concepts, in excellent
graphics, using a post in the ground and a steel rod against a block of ice (Fig 5).

Case often compared the controlled tooth movements of his contouring appliance
to the "ordinary" movements from other appliances. This was a direct criticism of
Angle, whose appliances at the time were designed only for ordinary or crown-
tipping movements. Angle, in turn, praised Calvin Case for designing appliances
to bodily move teeth. But, with his next breath (or stroke of a pen), Angle gave his
opinion on the subject --which excused the inability of his own appliances to
duplicate such movements: "…[T]he movement (bodily) is of uncertain utility in an
ordinary practice…[I] [believe] it is wholly unnecessary."4

Fig 5 Thought-provoking, allegorical illustrations by Case. (a) Violent, alternating pressures on the
top of post cause the bottom to move in opposite directions. The fulcrum lies somewhere between
the bottom and top of the ground. (b) Metal crowbar is stuck in the ground next to a fixed cube of ice.
If the bar is heated and the lightest of pressure is applied to its top (crown), the fulcrum remains at
the (root) tip on the ground. When the pressure exceeds the rate of melting (physiologic resorption),
the fulcrum moves up. Maximum pressure places the fulcrum at the top of the block (gingival crest)
and the tip is forced in the opposite direction. (From Case.6 )

ANGLE'S GREAT DILEMMA

Sometime after the publication of his sixth edition in 1900, which is replete with
extraction devices, Angle found himself in a dilemma. His new text included
appliances designed to tip teeth, yet by then he realized nature could not be relied
upon to subsequently upright them. He had no efficient mechanism to direct the
roots. Albin Oppenheim, a new faculty member at Angle's school, had done
research that indicated light forces were the most favorable for tooth movement.
Yet Angle's main source of force for closing extraction spaces was a traction
screw, a device that delivered undulating jolts of force at what are now considered
pathologic levels.

Angle appreciated that it was not advantageous to attempt to move a tooth while
keeping it upright--a tooth that cannot tip is, in effect, an anchor tooth. Yet Case
was achieving excellent facial and dental changes moving teeth bodily with his
contouring apparatus. Recognizing his dilemma and facing the facts, Angle came
up with the only instant solution to the problem--stop extracting teeth.

The decision had little to do with ideology or creationism. It had to do with

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practicality. Angle realized his appliances for treating extraction cases were
biologically and mechanically inadequate. In fact, the only "before and after" case
in his sixth edition was misleading in the facial changes created.4 Perhaps Case
was pointing this out during lectures and/or private conversations? This could
explain why Angle supposedly ordered S. S. White to recall the text, which also
served as a catalog for appliances and included traction screws, devices that he
could no longer recommend.

Angle presented his nonextraction stance in a paper read before the American
Society of Orthodontists in October 1902. He summarized his thoughts from that
paper in the preface to the seventh edition of his textbook2: "Many devices that
were formerly in favor with the author and still valued by many practitioners have
been placed in the Appendix in order to avoid confusion and for the reasons that
in the author's opinion they are not so efficient in meeting most of the demands of
treatment as the expansion arch in its present perfect state."

Bernstein 7 questioned why it took Angle 7 years to complete this new edition.
However, this length of time should be of no surprise to anyone involved in
appliance design and creation. The ideas do not come easily, construction plus
testing take time, and few appliances prove practical.

QUEST FOR THE ULTIMATE

NONEXTRACTION APPLIANCE

For the next 25 years, Angle continued his search for a better "mousetrap." This
led him through a series of nonextraction appliances, including the E (expansion)
Arch. These were followed by the pin-and-tube appliance of 1910 and the ribbon-
arch appliance of 1915.

Both the 1910 and 1915 Angle appliances were designed to expand the crowns
and then move the roots labially. The pin-and-tube was extremely difficult to
manipulate. The ribbon-arch bracket contained the first practical archwire slot,
which facilitated archwire changes and could provide torque with a ribbon
archwire. However, since the slots faced vertically, the teeth were free to tip
mesially or distally.

Finally, in 1925, as a means to provide positive mesiodistal angular control, Angle

invented what would become known as the edgewise appliance. The "open face"
or tie bracket was a clever modification of the ribbon-arch bracket. He cut an
archwire slot in its face and added an extension (wing) to its gingival end. The
labial wall of the original vertical archwire slot formed the incisal wing. The original
ribbon archwire was rotated 90 degrees and inserted "edgewise" into the
horizontally facing slot. 8,9 P. R. Begg, a student of Angle's in 1925, cut the first
prototypes on a lathe.

This resulted in the first positive, yet simple, 3-dimensional tooth control between
an archwire and slot. An archwire, round in cross section, could be used for initial
expansion to permit buccal or labial tipping of the crowns. Subsequently, a
rectangular archwire could be used to torque roots labially or buccally with hopes,
in some cases, of stimulating bone growth. The appliance, like the ribbon-arch,
was small and delicate, yet relatively easy to manipulate.

However, Angle's "latest and best" provided so much control it was difficult to
make the anteroposterior interarch corrections necessary to treat Class II or III
discrepancies. The archwire slot did not permit mesial or distal crown tipping.
Angle had forgotten the lesson he had learned 38 years before, "...[A] free hinge-
like movement of the tooth in retraction [must] be gained…." His last modification
to the appliance, second-order bends in the archwire, could not provide the free

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tipping required.

WORKING WITH THE ALBATROSS

Orthodontists have been fighting to overcome the limitations of the edgewise slot
for 75 years. The many difficulties encountered during treatment are accepted as
unavoidable facts of nature, when actually they are mechanically iatrogenic and
slot based. Articles and textbooks contain statements concerning the movement
of teeth and subsequent reactions as if they were inalienable.

"As soon as this mechanism (edgewise) was brought into use…no longer were
the molars the only anchor teeth--in fact, each and every tooth is now an
anchorage auxiliary,"10 wrote R. W. Strang in 1941. Strang, who became
frustrated with the edgewise mechanism's lack of provision for Class II or III
corrections, shared these thoughts with Angle's widow in 1931: "I feel very certain
that had Dr. Angle lived, his next development would have been the incorporation
into this mechanism of some means of producing anteroposterior movements in
the buccal sections of the arch. How he would have solved this, of course is
problematical and that it would have been in a way that none of us could
duplicate…I do feel certain that he would not have been satisfied to leave the
appliance inefficient in this one particular" (Personal correspondence between
R.W. Strang and A.H. Angle, 1931).

C. H. Tweed perfected a technique in the 1940s using tip-back bends to facilitate

retraction and close spaces in spite of the limitations imposed by Angle's slot. In
1941, he wrote, "…[C]uspid tip back bends are necessary. Their purpose is to
break down the…toe hold…present in the cuspid regions."11 His results were
excellent, but the price, as measured in long appointments, wire bending, and
patient cooperation, was extremely high.

Neither Tweed nor Strang ever suggested modifying the slot. They seem to have
considered it perfection itself. In the words of Tweed, "The last of Angle's many
mechanical contributions to orthodontics, the edgewise arch mechanism, is
unquestionably a great improvement over any previous appliance designed for the
treatment of malocclusions. Refinement may be possible in the future, but it is
difficult to conceive of improvement in this appliance so far as mechanical
principles are concerned."10

By the late 1920s, Begg had reverted to the use of ribbon-arch brackets. They
permitted all teeth to tip to facilitate anteroposterior interarch corrections and to
close extraction spaces. However, at that time Begg also lacked an efficient
means of mesiodistal axial control. This forced him to select cases for publication,
as Angle did with his traction screws, that required little or no root uprighting (Fig
6).

In the 1960s, Begg12,13 invented both the uprighting spring and torquing
auxiliaries. These enabled him and many others to utilize differential tooth
movement, crown tipping followed by root uprighting, to consistently treat the most
difficult of malocclusions (Fig 7).

PREADJUSTED ARCHWIRE SLOTS:

THE ALBATROSS GETS HEAVIER

Preadjusted archwire slots, especially in canine brackets, which tend to move their
crowns mesially, further complicate treatment. There is additional drag on
anchorage and when the archwires are first placed, the anterior bite may deepen:
"…[E]arly in treatment the (canine) slot angulation…can undesirably extrude

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incisors," 14 wrote L. F. Andrews in 1975. Nearly 20 years later, in 1991, R. P.

McLaughlin and J. C. Bennet wrote, "Preadjusted appliances tend to produce a
transitional deepening of the anterior overbite during leveling and aligning." 15

Fig 6 Four first premolar extraction case

treated by Begg in the 1950s. At the time, Begg
had no simple, efficient means of root
uprighting. Therefore, as did Angle with his
traction screw, he selected a malocclusion with
flared maxillary incisors that permitted
treatment by crown tipping only. The light
forces employed must have approximated
those imagined by Case, as the "ice" along the
roots melted such that treatment was
completed in just 4 months with 2 archwires
and little mesial movement of root tips. (From
Begg.12 )

Fig 7 Before, progress, and finish casts of a 4 first premolar extraction case treated by the Begg
technique in the early 1960s. Bite opening and space closure from light forces were made possible
by free mesial or distal tipping of all teeth except the first permanent molars. However, the modified
ribbon-arch brackets permitted excessive tipping, as seen in center cast, and extended treatment
time to 27 months. Finished cast demonstrates the ability of Begg's uprighting springs and other
auxiliaries to upright and torque teeth in the presence of round, main archwires. This case, treated by
the author, is on display in the re-creation of Angle's study at the Smithsonian Institute, Washington
DC, USA.

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Fig 8 Modification of Angle's edgewise archwire slot into a Tip-Edge slot. (a) Original slot with
parallel opposed upper and lower surfaces. (b) Removal of diagonally opposed corners to permit free
crown-tipping in one direction only. (c) Addition of lateral wings for increased rotational control plus
tie wing notches and vertical slot for auxiliaries. (From Kesling. 20,21)

Preadjusted archwire slots also set up more anchorage in the anterior teeth and
made space closure more difficult. However, the lure of automatic, precision
finishing caused many orthodontists practicing the Begg technique to change to
preadjusted edgewise brackets. In return, they gave up ease of bite opening,
retraction, and space closure for mesiodistal angular control throughout treatment.
The result was fewer extractions, more extraoral force, bimaxillary protrusions,
and an increased need for orthognathic surgery.

THE TIP-EDGE ARCHWIRE SLOT--

LIFTING THE ALBATROSS?

In 1986, the archwire slot was modified to lift the albatross. It has been achieved, I
believe, as Strang predicted Angle would have done it, by adding just the
necessary modification. That modification was the removal of opposed corners of
the conventional edgewise archwire slot to permit either mesial or distal crown
tipping (Fig 8).

The design, action, and advantages of the Tip-Edge archwire slot (Tip-Edge is a
registered trademark of TP Orthodontics, Westville, Indiana, USA) have been
clearly explained in previous articles 16-21 and proven in the offices of orthodontists
worldwide. Even though the Tip-Edge slot is preadjusted, it has none of the
previously mentioned disadvantages related to an unmodified, preadjusted slot.
The result has been as Coleridge phrased it over 200 years ago:

[A]nd from my neck so free

The Albatross fell off, and sank
Like lead into the sea.1

Not only does the Tip-Edge slot permit mesial or distal tipping, it automatically
provides variable anchorage as required, in one arch or the other by the simple
application of intermaxillary elastics.18

Such modification of the slot could not have been considered by Angle because
there were no mesiodistal uprighting springs at that time. The value of such
springs in differential tooth movement cannot be overemphasized. In fact, they
provide the optional and localized forces that make the Tip-Edge concept
possible. The evolution of the uprighting spring to its current form is shown in Fig
9.

Records of a patient treated with Tip-Edge brackets having modified archwire

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slots are shown in Fig 10. There was no need to set up or reinforce anchorage by
including second molars or installing a palatal bar. No second-order or tip-back
bends were required to permit retraction. The maxillary teeth were able to tip
distally under the lightest of forces with no incisal flexing of the archwire.

Fig 9 (a) Original mesiodistal uprighting spring introduced by Begg in 1961 for use with modified
ribbon-arch brackets. (From Begg.13 ) (b) Combination spring and lock pin (1974) eliminates need for
ligation. (c) Uprighting spring introduced by the author in 1988 for use with Tip -Edge brackets. Coil
rests on the side of the bracket to improve esthetics and hygiene. (d) Side-winder spring in place on
maxillary right canine bracket. Note: All springs shown are counterclockwise in action. (From
Begg,13 Kesling,22 Kesling.23 )

Fig 10 Before-and-after treatment casts of a 4 second premolar extraction case treated with Tip -Edge
brackets in 12 months and 7 adjustments. Four plain archwires (no second -order bends) were used
throughout treatment. Uprighting springs power both mesiodistal uprighting and, in the presence of
a passive rectangular archwire, labiolingual torque.

CONCLUSION:
The edgewise appliance with conventional, static archwire slots remains the most
popular in the world today. When the appliance was introduced in 1925, Angle
claimed everyone who tried it would approve. For those who looked the other way,
he had these words: "I feel sure [it] will be found to be more practical and

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efficient…than anything previously available, at least by those who are not in a 'rut
and contented'." 8 Ironically, the original, unmodified edgewise slot has proved as
restrictive as the ruts in the road to which he referred. Yet, a slight alteration made
to the mechanism in 198619 finally provided a simple means of producing
anteroposterior movements in the buccal segments. This modified slot not only
promotes space closure, but through light, intermaxillary forces, enhances the
retraction of one dental arch while automatically creating anchorage in the other.

The author believes Doctors Strang, Tweed, Begg, and even Angle himself, would
approve of its simplicity and efficiency. In retrospect, and with respect, we must
remember Angle only said, "My work is done." As another who has also agonized
over the design of orthodontic appliances, especially brackets, it is clear, "The
work is never done."

ACKNOWLEDGMENT

Dr. Kesling is a shareholder of TP Orthodontics, which manufactures and markets

the Tip-Edge bracket. Now, you can order Tip-Edge products over the Internet!
Visit www.tportho.com and visit the world's FIRST online orthodontic store!

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