MBT SYSTEM

Beatriz Triay

3rd master's degree in

orthodontics
 INDICE

I. INTRODUCTION

II. ELEMENTS THAT MAKE UP THE MBT PHILOSOPHY

1. Bracket selection

2. Versatility of the bracket set

3. Accuracy in bracket placement

4. Light continuous forces

5. 0.022" groove vs. 0.018" groove

6. Anchorage control in the initial stages of treatment

7. Group movement

8. The use of three arc shapes

9. 0.019" x 0.025" rectangular steel work bow

10. Hooks on the arches

11. Methods to bind the arches

12. Awareness of dental discrepancies

13. Persistence in finishing

III. ALIGNMENT AND LEVELING PHASE

III.1/ recognition of the anchoring needs of a case

III.2/ decrease in staging anchor requirements

III.3/ the anterior-posterior anchorage

III.4/ vertical anchoring

III.5/ control of anchorage in the transverse plane

III.6/ sequence of arcs

IV. LEVELING AND CONTROL OF THE OVERBITE

IV.1/ treatment without extractions

IV.2/ treatment with extractions

V. CLASSES II

V.1/ movement of the upper incisors

V.2/ movement of the lower incisors

VI. CLASSES III

VI.1/ movement of the upper incisors

VI.2/ movement of the lower incisors

VII. GAP CLOSURE AND SLIDING MECHANICS

VIII. CASE COMPLETION

IX. RETENTION
 I. INTRODUCTION

The MBT philosophy of orthodontic treatment has been developed over a period of

more than twenty years, bringing together the efforts of its three main creators:

 Dr. Richard Mc Laughlin (San Diego, California)

 Dr. Jhon Bennett (London, England)

 Dr. Hugo Trevisi ( Sao Paulo, Brazil)

The fundamentals of orthodontic treatment mechanics are determined by four

elements:

 Bracket selection

 Placement of brackets

 Selection of arches

 Force levels

Between 1975 and 1993, McLaughlin and Bennett worked with straight arch

appliance (SWA) brackets, placed in the center of the clinical crown. In most cases,

an ovoid arch shape of intermediate size was used. Slip mechanics, with light forces,

were recommended with 0.019" x 0.025" steel arches and 0.014" light termination

arches.

Between 1993 and 1997 McLaughlin, Bennett and Trevisi, having reviewed Andrews'

findings and taking into account research of Japanese origin, completely redesigned

the bracket system to complement their proven treatment philosophy and overcome

the limitations of the original straight appliance. This new generation of MBT

brackets is a version of the pre-adjusted bracket system specifically designed to be

used with light and continuous forces and to work ideally with sliding mechanics.

These brackets are placed with the aid of calipers for greater vertical accuracy and

ovoid shaped archwires are still used in most cases.

These same three authors, between 1997 and 2001, addressed the issues of arc

selection and force levels to complete their mechanics. Recent research has shown

that three basic arch shapes are necessary: narrow, square and ovoid. Superimposing

the three arch forms shows that the greatest difference is found in the width at the

canine and premolar levels. They include the use of thermo-activated nickel titanium

arches.

II. ELEMENTS THAT MAKE UP THE MBT PHILOSOPHY

Bracket selection

The MBT system apparatus is based on the figures obtained in the original Andrews'

research and has the following characteristics with respect to the original Straight Arc

and Roth's technique:

 Decreased angulation of upper and loweranterior brackets. This aids

treatment mechanics because it reduces anchorage requirements, reduces the

tendency for the overbite to increase in the early stages of treatment and

reduces patient coperation.

 Decreased angulation in upperposterior brackets and tubes. This angulation

places the crowns of these teeth in a slightly more vertical position, which

contributes to a significant reduction in the need for anchorage for these teeth.

 Maintenance of this angulation in the lower posterior brackets.

 Increased torque in the upper and lower incisors.

  Three torque options on upper and lower canines. The options with 0º and +7º

in the upper canine are preferred in cases with narrow maxillary bone bases

and prominent canine roots. In the lower canine the most used torque is -6º.

 Maintenance of -7º torque in the upper premolars.

 Increased torque in the upper molars.

 Decreased torque in lower premolars and molars.

two sizes of steel metal brackets are available, a smaller one for shorter clinical

crowns (Victory Series brackets) and a larger, standard size for larger teeth (standard
size "Full size" twin brackets) which increases the bonding area and increases tooth

control.The larger, standard size for larger teeth (standard "Full size" twin brackets)

increases the bonding area and increases tooth control. A ceramic bracket reinforced

with metal clarity (Clarity brackets) is also available.

The rectangular shape of the standard brackets of the original straight arch appliance

has been replaced by a rhomboid shape. This reduces the volume of each bracket and

allows for reference lines in both the vertical and horizontal planes, thus contributing

to placement accuracy.

Versatility of the bracket set.

They are designed to be able to solve most treatment difficulties. This versatility is

useful both to control inventory costs and to avoid unnecessary bends in the wire.

There are seven different bracket and tube possibilities, this creates a platform for the

bracket and archwire set to produce the necessary individualization and

overcorrection for certain types of cases.

1. options for palatally displaced lateral incisors: 180°

rotation of the bracket, torque changes from 10° to -

10°.

2. three torque options for upper canines (-7,0º,+7º)

3. three torque options for lower canines (-6º,0º,+6º)

4. interchangeable lower incisor brackets

5. interchangeable upper premolar brackets

6. use of upper 2nd molar tubes in upper 1st molars

when an extraoral arch is not necessary

 7. use of 2nd mol inf tubes in the 1st and 2nd upper

molars on the opposite side when finishing a case in

CII

Accuracy in bracket placement

The brackets are placed in the center of the clinical crown, with calipers.

Recommended bracketing schedules or individualized schedules can be used for the

following cases: pointed teeth (upper canines and lower 1st premolars), abnormal

incisal edges, overbite and open bite, extraction of premolars.

Light continuous forces (below 200gr)

The technique requires the use of light continuous forces. The authors believe this is

the most effective way to move teeth, increase patient comfort and reduce anchorage.
These are especially important at the beginning of treatment when thin, flexible

archwires with minimal deflection are used and frequent archwire changes are to be

avoided. At a more advanced stage of treatment, during the sliding mechanics phase,

gentle, continuous forces are applied with active back ligatures and 0.019" x 0.025"

working arcs. In the later stages, 0.014" light steel or 0.016" NTT archwires are used

for tooth position detailing and setting.

The 0.022" slot vs. the 0.018" slot.

The preset device seems to work best in its 0.022" version. the larger size of the slot

allows greater freedom of movement with the initial arches and therefore helps to

limit the level of forces. In more advanced stages 0.019" x 0.025" steel working

arches work well.

anchorage control in the initial phases of treatment

in the 1st phases of treatment, the greatest threat to anchorage control comes from the

inclination of the anterior brackets. Compared to previous generations of the pre-fitted

appliance, the MBT brackets have a lower inclination. This, combined with the

lightweight archwires, results in less need for anchorage in the first stages, reducing

the need for extraoral archwires, palatal bars or lingual archwires.

Retroligatures are used to help control canine crowns in cases of premolar extractions

and in some cases without extractions.

At the beginning of the treatment, distal bends are used, except in cases where it is

necessary to increase the arch length. These ensure patient comfort and help prevent

mesial movement of the anterior teeth, which is undesirable in most cases with the

exception of CII2 and some CIII. Distal bends and retro-ligations are maintained

throughout the alignment and leveling phase until the rectangular steel arch phase is

reached.

group movement

whenever possible. For example, in the case of extractions of premolars, the retro-

ligatures are used to control the canines and retract them sufficiently to allow the

incisors to be aligned. Then, the anterior segment is handled en masse, as a group of

six or eight teeth.

The use of three arc shapes

In the late 1990s, the authors found it beneficial to use three shapes of square and

narrow ovoid arches. The narrow shape has the smallest intercanine width and is

suitable for cases with narrow jaws, the square shape is suitable for patients with wide

arches and in cases where vestibular straightening of the lower posterior segments and

expansion of the upper arch is necessary. Currently, the recommended technique for

all cases is to create individualized shapes based on the three shapes.

a single size of 0.019" x 0.025" rectangular steel arc

The possibility of using thicker bows has been evaluated but, although they provide

better control, they are less effective in sliding mechanics. In the later stages the use

of NTT (thermal nickel titanium) or 0.021" x 0.025" steel archwires is sometimes

considered to get the bracket information fully expressed. The technique is based on

full arches and rarely uses closing springs or sectional arches.

Hooks on the arches

The 0.019" x 0.025" steel working arches typically have welded hooks that are useful

for many aspects of processing mechanics. The average distance of the clasps in the

upper arch is 36-38mm and in the lower arch 26mm. There is greater variability in the
position of the clasps in the upper arch due to variations in the mesiodistal dimensions

of the upper lateral incisors.

the clasps can be used in combination with molar tube clasps or with 2nd premolar

tubes. They can be used for space closure with group movement (A) and closed space

ligation (B), long (C) or short (D) CII elastics as well as CIII (E) or vertical elastics

(F).
Methods to bind the arches

Both with the initial 0.016" NTT archwires and the first two months of using the

0.019" x 0.025" steel working arch, the use of elastic ligatures is recommended. Then

0.010" metal ligatures are used.

Awareness of dental discrepancies

Checking the tooth size when planning the treatment is part of the technique and it is

accepted to perform stripping at the level of the lower incisors to achieve a correct fit

of the teeth in the last phases of the treatment.

Persistence in finishing

Lightweight arches such as 0.014 steel arches are used and it is often necessary to

make bends in the arches.

 III. ALIGNMENT AND LEVELING PHASE

This phase can be defined as the tooth movements necessary to achieve the passive

engagement of a rectangular wire with a dimension of 0.019" x 0.025" and a suitable

arch form in a pre-fitted appliance with correctly placed 0.022" slot brackets.

III.1/RECOGNITION OF THE ANCHORING NEEDS OF A CASE

In each case a goal is set for the final position of the incisor in the facial complex, this

is the determination of the "planned incisor position" or PPI. In the early stages of
treatment, anchorage needs can be decided by comparing the initial position of the

upper and lower incisors with the final IPP.

The anchorage should be managed in this phase to ensure that the incisors do not

change position, or that if they do, it is in a favorable direction. The major concern

relates to ant-post movements, but torque control and vertical situation should also be

considered.

With the help of the dental VTO, position changes and anchorage needs of canines

and molars are determined. These teeth must present no change, or a favorable

change, according to the requirements detected in the VTO.

Example of a CII/1

at the beginning of the treatment, the upper incisors are in front of the IPP, so a

complete control of the anterior-posterior anchorage is necessary to limit mesial

movement and the increase of the protrusion. This involves the use of retroligatures

and distal bends and may require the support of a palatal bar, an extraoral arch or CII

elastics.

The lower incisors will be located above or behind the IPP. To avoid undesired

proinclination, anchorage control is necessary.

As in most cases, excessive arch forces should be avoided to eliminate the risk of a

"roller coaster" effect and increased overbite.

Example of a CIII
upper anchorage control is only necessary if there is a risk of excessive anterior

inclination of the upper incisors beyond the PPI.

Normally the lower incisors will be in front of the IPP, therefore in the lower arch it is

necessary to control the anchorage as much as possible with distal bends and retro-

ligations and possibly with a lingual arch and/or CIII elastics.

Example of bimaxillary protrusion

full anchorage control is usually necessary in both arches because the upper and lower

incisors are in front of the IPP.

Example of bimaxillary retrusion : CII/2

it is not necessary to anchor the brackets so that the inclination of the brackets can be

expressed freely.

III.2/DECREASING ANCHORING REQUIREMENTS AT THIS STAGE

 Bracket design

Any reduction in bracket inclination is beneficial in reducing the anchorage

requirements of a case. The MBT bracket set compared to the original straight arch

appliance has 10° less distal root inclination in the anterosuperior segment and 12°

less distal root inclination in the anteroinferior segment. This reduces anchorage

requirements, decreases the tendency for an increased overbite and reduces patient

cooperation.

 Very light arch forces and avoid very frequent arch changes

 Avoiding the use of elastic chains

For retraction mechanics especially in cases of extraction of first premolars.

III.3/ ANTEROPOSTERIOR ANCHORAGE

Retroligatures for anteroposterior control of canines

are 0.010" or 0.009" metal ligatures that extend from the last embanded molar to the

canine. They limit the mesial inclination of the canine during alignment and leveling.

They are normally used in cases of premolar extractions but may also be necessary in

cases treated without extractions where there is a threat to the anchorage. They are

passive elements that are placed before the arch and must be tightened 1-2 mm during

monthly check-ups. They are left in place until NTT's rectangular arches are placed,

including the ones in NTT.

It is preferable to keep the 6 or 8 anterior teeth as a group and if a space appears

between the canine and lateral teeth, the retro-ligation is removed.

distal bends for anteroposterior control of the incisors

They are maintained throughout this phase until a rectangular arc of NTT included is

placed.

Control of anteroposterior anchorage of lower molars

the lingual arch: in cases of premolar exos and maximum anchorage and in cases of

late mixed dentition with slight crowding to maintain the drift space.

CIII elastics and extraoral arch: in cases of severe lower crowding and where more

anchorage is required than can be provided by a lingual arch. CIII elastics can be

placed simultaneously to prevent extrusion of the incisors. The authors prefer to delay

the placement of elastics until a 0.016 round steel arch has been placed.

Control of anteroposterior anchorage of upper molars

The extraoral arch: For cases in which it may be necessary to limit mesial movement,

maintain position or even distalize the posterosuperior segments.

The palatal bar.

III.4/ VERTICAL ANCHORING

Vertical control of the incisors

The inclination included in the anterior brackets of the preadjusted appliance provides

a tendency for a transient increase of the overbite in the 1st phases of treatment. If, in

addition, the canines present a distal inclination at the beginning, the effect is greater.

This effect can be avoided either by not placing brackets on the incisors at the

beginning or by not ligating the archwire in the slot. The arch is allowed to remain

incisal to the groove until the canines have straightened and moved distally under the

effect of the relines.

Vertical control of canines

In the 1st stages the canines that are high vestibularly can be gently ligated to the

0.015" braided or 0.016" NTT archwires. If the initial archwire is fully engaged in the

bracket slot of the canine, it may cause undesirable movement of the adjacent teeth,

lateral incisors and premolars.

vertical control of molars in hyper-divergent cases

the second molars are not initially included in the setup to minimize the extrusion

effect.

If expansion is to be done, it should be done en masse to avoid extrusion of the palatal

cusp.

If a palatal bar is used, make it low for intrusive effect.

If an extraoral archwire is used, it should be of high or combined traction.

In some cases it is useful to add a posterior bite plane.

III.5/ CONTROL OF ANCHORAGE IN THE TRANSVERSE PLANE

In most cases no special measures are necessary, however, in all treatments attention

should be paid to the intercanine width and in some treatments molar cross occlusions

are important. Small cross-occlusions can be corrected in the final phase of alignment

and leveling by using rectangular arches that are slightly expanded.

III.6/ SEQUENCE OF ARCS

The introduction of thermo-activated wires has provided a beneficial substitute for a

number of traditional stainless steel wires and can dramatically increase the efficiency

of orthodontic treatment. However, this substitution is beneficial only for initial dental

alignment procedures. There are clinical situations in which thermo-activated wires

are not recommended, due to their flexibility, or in which steel wires should also be

used:

 Initial wires in cases of severe misalignment. In these cases it is better to place

a stranded wire 1st.

 When using re-ligatures to retract the canines in case of crowding treated with

extractions. To minimize tilting of the canines, a 0.018" or 0.020" steel wire

should be placed as soon as possible.

 When open springs are used to create space for locked teeth. These should not

be used until a 0.018" or 0.020" steel wire has been placed.

 For total leveling and overbite control.

 For torque control. Thermo-activated rectangular wires initiate the process but

this movement is best done with steel wires.

 Closing of spaces and reduction of protrusion. The stiffness of rectangular

steel wires is required.

sequence B: sequence most commonly used since the appearance of thermo-activated

arcs.

sequence A: traditional sequence that still has to be used in situations such as those

mentioned above.
IV. LEVELING AND CONTROL OF THE OVERBITE

Correction of the overbite is achieved with several movements:

 Eruption/extrusion of posterior teeth.

 Distal inclination of the posterior teeth.

 Proinclination of the incisors.

 Intrusion of incisors.

 A combination of two or more of the above movements.

IV.1/ TREATMENT WITHOUT EXTRACTIONS

It usually favors the opening of the bite due to a distal inclination of the posterior

teeth and a proinclination of the incisors. There are a number of factors that help to

level the arch and control the increased overbite:

 Initial arch placement and expression of bracket inclination.

 Use of a bite plane: in hypordivergent cases, a removable plate or direct luting

material can be used on the palatal side of the upper incisors.

in average or hyperdivergent cases it is useful to place the same type of material on

the occlusal surface of the 1st molars.

 the importance of incorporating the second molars, especially the lower ones,

into the appliance as soon as possible.

 Torque. During leveling with round wires, changes in torque occur, especially

in the anterior teeth.

 Bite opening curves. The authors prefer not to place them on round wires or to

have preformed NTT-type wires with built-in bends. Only in cases where

leveling and correction of the overbite has not been completed after using

rectangular steel wires for 6 weeks, it is acceptable to add bends to the wires.

In the upper arch the radicular-palatal torsion of the upper incisors is

increased, this is beneficial and it is usually unnecessary to add any further

bending. In the lower arch it causes a proinclination of the incisors, which is

often not indicated. Therefore, 10º to 15º of radicular-vestibular torque should

be added. The net effect in the mouth will be a retroinclination and intrusion

of the lower incisors.

  CII or CIII intermaxillary elastics are used to correct anteroposterior problems

and it is recommended to use them with rectangular steel wires, and they can

contribute to the opening effect by collaborating in the extrusion of the molars.

 Spacing in non-extraction cases: space closure should not be attempted until

the overbite has been fully corrected and complete leveling has been obtained.

IV.2/ TREATMENT WITH EXTRACTIONS

The procedures described for cases without extractions also apply to cases with

extractions. There are two additional factors:

 The lower incisors are held in position or slightly retracted. This makes it

difficult to open the overbite.

 If attempts are made to close spaces before correct leveling and overbite

control is achieved, the overbite will worsen because the arches are deflected

and cannot slide effectively through the grooves due to friction. The authors

prefer to perform a mass retraction of the entire anterior group with a

 rectangular steel wire when leveling and alignment is completed. In cases with

anterior crowding, it is advisable to first retract the canines, maintaining an IC

relationship until there is enough space to align the incisors and then proceed

with mass retraction. This is done with the use of active retro-ligatures applied

to the canines, to avoid distal inclination of the canines and to control and

limit the tendency to mesial inclination of the anterior teeth due to the

information incorporated in the brackets. Elastic forces should be avoided

because they can cause excessive distal inclination of the canines and

consequently opening of the posterior bite. This phenomenon has been called a

"roller coaster".

 Importance of the use of light forces. Heavy forces can cause an increase in

overbite in two ways: the canines can tilt towards the extraction space so that

the sliding mechanism is not effective and at the level of the incisors the

torque control is exceeded causing a distal tilt.

The addition of a small amount of torque to the upper arch in the incisova

region, combined with light forces (150-200gr), is usually sufficient to

minimize these two factors.

V. CLASSES II
During the development of the treatment plan, a 4-step process is followed:

 Stage 1: determination of the PPI (planned incisor position) for the upper

incisors. In some cases it will be an achievable objective, in others it will be

 necessary to accept an IPP that represents an acceptable compromise for the

case.

 Stage 2: determination of the IPP for the lower incisors with respect to the IPP

of the upper incisors. If this cannot be achieved with orthodontics alone, it will

be necessary to modify the IPP of the upper incisor or consider combined

treatment with surgery.

 Stage 3: Determination of the position of the remaining lower teeth to match

the IPP of the lower incisor. In this phase, dental VTO is used to solve the

mandibular discrepancy and to decide whether or not to perform extractions.

 Stage 4: determination of the position of the remaining upper teeth to fit the

lower teeth, management of the discrepancy and necessary mechanics.

V.1/ MOVEMENT OF THE UPPER INCISORS

V.1.1/ Mesial movement of the upper incisors :

In CII/2 the incisors are normally retracted, during the alignment and leveling phase

they move towards vestibular approaching their PPI and becoming a CII/1. In

adolescents it can be treated with conventional orthodontics but in some adults

surgery will be necessary.

The initial phases can be handled in two ways:

1. The upper arch can be started 1° and once the rectangular arch stage has been

reached, appliances can be placed in the lower arch.

2. Appliances can be placed in both arches together with a bite plane plate for the

first few months to free the bite and prevent breakage of the lower brackets.
A normal sequence of arches will be used starting with braids. The length of the upper

arch increases during the first months and the distal bends should be made 1 mm

distal to the molar tubes.

V.1.2/ distal movement of the upper incisors:

In cases of some C II/1 presenting very advanced upper incisors and associated with

anterior spacing.

A sliding mechanism is used on a normal rectangular working arch and active distal

ligatures are necessary for retraction and space closure. In some cases an elastic chain

on the four anterior teeth is added after alignment and leveling is achieved.

The necessary anchorage must be available (palatal bar, nocturnal extraoral arch, CII

elastics).
V.1.3/ distal movement of the upper incisors after premolar extraction:

To retract the incisors, a sliding mechanism is used on a steel working bow.

Retraction force is obtained from active distal ligatures and it may be necessary to add

a small amount of torque in the anterior arch zone to maintain torque control of the

incisors. Anchorage may be required and prior leveling of the lower arch is necessary

so that there is no interference of the lower incisors.

V.1.4/ distal movement of upper incisors in cases without extractions or

spacing

In some cases of CII/1 it may be decided to carry out the treatment without

extractions and distalize the lateral segments to allow the retraction of the incisors

towards their IPP. If the movement is minimal (1-3mm), the disrotation of the 1st

molar usually solves the problem. In this situation an extraoral arch and a sliding arch

are useful. If the necessary space exceeds 3 mm, a distalizing appliance can be used in

combination with the extraoral arch, but these cases are a great challenge for the

orthodontist who often decides to perform extractions.

V.2/ MOVEMENT OF THE LOWER INCISORS

V.2.1/ Movement of the lower incisors in the mandibular bone

The range of motion of the incisors in their basal bone is limited. Mesial movement is

achieved primarily with vestibular tilt and a change in torque. A reasonable limit for

proinclination is 100° to the mandibular plane and +2mm to Apo.

The -6° lower incisor bracket torque of the MBT system helps prevent excessive

proinclination. If the case requires it, a well aligned lower arch with a well ligated

working arch can be used as a support for the CII elastics for the retraction of the

upper incisors.

V.2.2/ change in mandibular length

V.2.3/ change in the anteroposterior position of the mandible due to

changes in the position of the condyles in the fossa.

These last two points would require the use of a functional device.
VI. CLASSES III
The treatment plan development sequence is similar to the IIC method, with the four

steps mentioned above.

VI.1/ UPPER INCISOR MOVEMENT

It is useful to plan the movements of the upper incisors in isolation and then consider

the movement of the lower incisors. The lower arch can be dispensed with at this

stage except when it is needed as an anchorage source for the CIII elastics.

In most cases of CIII (non-surgical) it is necessary to move the upper incisors

forward. This can be achieved in two ways:

1. By proinclination and anterior movement within the available

bone.

While aligning the teeth with the initial wires there is a tendency for the upper

incisors to move forward because of the inclination included in the bracket. In

cases of CIII this is a beneficial effect and moves the incisors towards their

IPP. Similarly, in NTT and steel rectangular arch phases, the effects of

anteroposterior expansion and torque tend to produce beneficial changes. This

can be further enhanced by the use of CIII elastics. Because of these

spontaneous effects during dental alignment and leveling, the management of

light CIII is straightforward.

There are clear clinical limits to this movement. There are two risks:

 Excessive proinclination: it should be avoided to go beyond 120º with

respect to the maxillary plane, as this may cause gingival and gingival

recession and excessively long clinical crowns.

 Failure to achieve a positive highlight. There is a risk of enamel

erosion and root resorption.

In these two situations it would be better to treat the case with surgery.

2. By mesial movement of the maxillary bone as a result of natural

growth or orthopedic procedures.

VI.2/ LOWER INCISOR MOVEMENT

Distal movement of the lower incisors can be achieved in two ways:

1. By distal movement and retraction of the lower incisors in the

mandibular bone.

Retraction or retroinclination beyond 80º with respect to the mandibular plane

should be avoided because of the risk of dehiscence and lack of tooth support. It is

usually achieved with the help of CIII elastics and the mechanics is easier in those

cases where premolar extractions have been performed.

A non-extraction approach to the treatment of CIII may not achieve sufficient

movement of the lower incisors for the needs of the case. Therefore, there is no

reservation for the possibility of late changes due to growth, which are quite frequent,

especially in males.

2. By distal movement of the mandibular bone due to orthopedic

procedures.
VII. GAP CLOSURE AND SLIDING MECHANICS
There are four methods for closing spaces:

1. Bows with locking handles: they are part of the traditional standard edge bow

mechanics. The authors occasionally recommend them to close small residual

spaces, especially in adults.

2. Sliding mechanics with intense forces (ex - edge bow): cause undesirable

changes in tilt, rotation and torque in response to excessively rapid gap

closure.

3. Elastic chain: the authors recommend them only to close one or two small

spaces at the end of treatment and to prevent the spaces from reopening at later

stages of treatment when the 0.014" completion archwires are in place.

4. Sliding mechanics with light forces. The authors recommend the following

technique:
  0.019 x 0.025" steel archwires in a 0.022" slot because they

provide good overbite control and allow sliding of the posterior

sectors.

 0.7" soldered brass hooks. Alternatively, 0.6" welded hooks made

of distempered steel can be used.

 Passive distal ligatures. It is recommended that the working arch be

left in place for 1 month with passive distal ligatures before starting

space closure. This allows the torque changes of individual teeth to

take place and the leveling to be completed so that, when the active

distal ligatures are placed, the sliding mechanics can be carried out

smoothly. They go from the molar hook to the arch hook.

 Active distal ligatures with elastomeric modules , although they

can also be used with nickel titanium springs when the spaces are large or

the patient has impediments to regular visits.

 Active distal ligation type 1 (distal module). The steel working bow

is attached to all the brackets. The elastomeric module is hooked into the

hook of the 1st or 2nd molar. A 0.010" ligature is used. one end of the

ligature is passed under the arch. This increases the stability of the active

distal ligation and helps to keep the ligation away from the gingival

tissues.
 active distal ligation type 2 (mesial module). The principle is the

same as type 1, but the elastomeric module is hooked on the hook welded

to the arch. The working arch is ligated on all brackets except the

premolars.

a 0.010" metal ligature is hooked to the hooks of the 1st or 2nd molars and,

braided a few times on itself, is hooked on the other end to an elastomeric

module attached to the archwire hook. Finally, an elastomeric module is

placed in the premolar bracket covering the active distal ligature and the arch.

With both distal ligatures the module is tensioned to activate it until it reaches

a size twice its initial diameter. It should be changed at each visit. In some

cases, at the end of space closure, it may be useful to supplement the active

distal ligation with an elastic chain from molar to molar.

VIII. CASE COMPLETION
VIII.1/ HORIZONTAL CONSIDERATIONS

VIII.1.1/ correct inclination of the anterior and posterior teeth

Tilting is one of the strengths of the preadjusted appliance, especially when using twin

brackets of sufficient width. Almost the entire inclination incorporated in the bracket

is expressed with little effort and no bending is required.

VIII.1.2/ adequate torque to the incisors

This is one of the weaknesses of the preset device and of any system based on the

edge arc. In designing the MBT, the authors decided to increase the torque of the

upper central incisors by 10°, the upper lateral incisors by 7° and the lower lateral

incisors by 5°. Even so, it is often necessary to make 3rd order bends in rectangular

steel wires, at an anterior level.

VIII.1.3/ rotation control

The vestibulo-lingual compensation included in the preadjusted appliance together

with correct bracket placement is very effective in controlling rotations.

If there are rotations at the beginning of the treatment, it is useful to place the bracket

slightly towards the existing rotation.

VIII.1.4/ maintenance of all enclosed areas

While the rectangular arches are in place, this can be achieved with passive distal

ligatures. And with retroligatures from molars to canines when light wires are placed.

In the settling phase of cases with extractions, ligatures are placed at 8 across the

extraction spaces.

VIII.1.5/ horizontal overcorrection

In CII and CIII, once the horizontal problem is corrected, the elastics are removed and

the patient is observed for a period of 6-8 weeks. If the case is stable, the device can

be removed. If not, overcorrect with light elastics, wearing the CIIs in edge to edge

relationship and hold in this position for 6 to 8 weeks and then eliminate the elastics

or wear them only at night to see how the case settles. In cases of CIII it can be

overcorrected by producing a 2-3 mm protrusion and then kept under observation as

in CII.

VIII.2/ VERTICAL CONSIDERATIONS

VIII.2.1/ correct length of the crowns, relationship between marginal

ridges and contact points

These corrections must be made at the rectangular arches stage to be stable, otherwise

they will be made at the detailing and finishing stage.

The authors recommend the use of individualized tables for correct bracket placement

to reduce the need for minor bends in the archwire.

For example, upper canines and lower 1st premolars often have pointed cusps and in

these teeth the braccket has to be placed 0.5mm further to the gingiva.

VIII.2.2/ vertical overcorrection

In cases with enlarged overbite or open bite it is beneficial to achieve some

overcorrection. This process begins as early as the bracketing phase. These can be

placed 0.5mm more to the gingival in open bites and 0.5mm more to the incisal in

augmented overbites.

VIII.3/ CROSS-CUTTING CONSIDERATIONS

VIII.3.1/ arch form

VIII.3.2/ coordination of arcs

Some cases may present at the end of the treatment a slight compression of the

posterior part. A 0.045" archwire can be used with the shape of the upper arch and

widened about 6mm per side. It is attached to the tubes for the extraoral arch.

VIII.3.3/ transverse overcorrection

In cases where maxillary expansion is performed at the beginning of the treatment, a

palatal bar should then be placed and remain in place until the rectangular steel arch

phase is reached. In this phase it is beneficial to torque the brackets in the posterior

part as well as to add some radicular-vestibular torque in the posterior part of the

archwire. This allows the posterior segments to seat properly.

VII.4/ THE FINAL PHASE OF FINISHING: SETTLING THE CASE

A 0.014" or 0.016" NTT archwire is used in the lower arch and a 0.014" sectional

archwire from lateral incisor to lateral incisor is used in the upper arch. These wires

can be accompanied by vertical elastics where settlement is required. The better the

bracket placement, the less elastics will be needed.

During this phase, patients should be visited every 2 weeks. The first 2 weeks the

elastics can be worn all day and 2 more weeks at night. The appliance removal visit

can then be scheduled.

IX. RETENTION
The methods used in this technique for retention are the same as for any other

technique.

The authors routinely use a 0.015" or 0.0195" wire braided wire fixed retainer in the

lower arch for most patients. These go from canine to canine and in cases of

extractions usually extend to the mesial fossa of the second premolars.

Upper fixed retainers are not used as frequently because of the ease of fracture due to

occlusal contact. However, in many adult cases they are essential.

It is increasingly common to consider the use of fixed retainers placed vestibularly for

the upper incisors. They may be useful as a short-term measure for adult patients who

wish to have their brackets removed quickly. After a few months it is possible to

switch to traditional retention methods.

Positioners, removable retainers (Hawley plates, circumferential) or thermoformed

retainers can also be used.