The New Torqued Appliance

It is more efficient and less time consuming to have torque cut into the bracket than to torque the archwires. What we are trying to do with the New Torqued Appliance, by incorporating torque and other features into the brackets, is to build in 90% of the treatment, leaving 10% for adjustments. This is in contrast to most appliances requiring 90-100% adjustments.

The basis for this technique is the Steiner Spring-Wire bracket (Fig. 1), which is supplied with .018 and .025 channels. A difference between the Steiner and the Lewis brackets is in the texture of the wings. The Lewis bracket wing is rigid, whereas the Steiner Spring-Wing is flexible. That gives you some flexibility from the wings in addition to what you get from the archwire. Unitek made a modification in the attachment of the Steiner bracket and wing to the band. They don't weld through the wing. The bracket is placed over the wing and welded to the band using welds around, but not through, the wing. While this means that you can't buy these brackets and weld them yourself, it has been a most important step in preventing breakage of the wings.

Those who are accustomed to adjusting a Lewis bracket wing with a How plier, will break a Steiner wing with the same adjustment. However, a simple tool is available which permits adjustment of the Steiner wing easily and without breakage. The brackets are available on band strips or on preformed bands, and they can be fitted directly or indirectly.

I have used an indirect technique for seven years. But, there is the flexibility of using either a direct or an indirect technique with band strips or preforms. If an orthodontist wants to try a few cases using the New Torqued Appliance, before purchasing a large inventory of preformed bands and prewelded brackets, I would suggest that he use the band strips with an indirect technique. If he is already using an indirect technique, it is a simple matter to buy what brackets he needs on band strips. Or, he can use the laboratory that I use (Jim's Orthodontic Laboratory, Inc., 5928 Westheimer, Houston, Texas 77027) and it is even more simple.

If someone wishes to try an indirect technique, I would suggest that he be selective in his cases. They should have all the teeth present and fully erupted so that he can get a complete set of bands from the lab. The teeth don't have to be separated for the impression. All that is required is a rubber base impression, including all the teeth and the tissue behind the terminal teeth. SIR is also a good material. That goes to the lab and the lab returns a full set of bands ready for cementation.

If there are teeth that are unerupted for which bands cannot be made initially; or if there is extreme crowding that prevents you from getting a decent impression of all the teeth, as for example with an overlapping cuspid and lateral from which you can only cut a die for one of them; or in the event of breakage or a band doesn't fit from the set that was made indirectly-- to cover all these circumstances, we have prepared a limited inventory of bands in a compartmented box with spaces for the various kinds of brackets on band strips. One would only need 4 or 5 of each torque

and angulation. For those not trained at direct band fabrication, an introductory preformed selection of bands would be necessary.

Built-in Torque (Fig. 2)

The brackets for this technique are supplied with lingual root torque cut into the upper incisor brackets-- 7° on the centrals, 3° on the laterals. From the upper cuspids posteriorly, the brackets are supplied with labial root torque-- 7° on the cuspids, 7° on the bicuspids, 10° on the molars. On the lower teeth, the torque in the brackets is O° on the incisors, 7° on the cuspids, 15° on the bicuspids and 25° or 30° on the molars. We recognize that there are situations, such as a Class II division 1 with upright upper anteriors, where you might want to overtorque. However, it would be impractical to try to supply an inventory of bands to cover every possible torquing need. We believe that the torques supplied will avoid a majority of adjustments in a majority of cases. The appliance could not be 100% and, in addition, there is not 100% torque activity between the wire and the bracket. Therefore, in cases which are not satisfied by the torque supplied in the brackets, you do adjust the rectangular archwire to obtain the eyeball or cephalometric result that you desire. No torquing auxiliaries are used. If torque is needed, it is adjusted in the rectangular wires.

Built-in Angulation

Standard angulation is built into the brackets in this technique to what we consider to be an average artistic positioning of the roots of the teeth (Fig. 2). This may satisfy the esthetic requirements for practically all of the cases. For the others it may be too much or too little, and for those cases you do have to adjust the archwire for optimum results.

We build in the following angulations on the indirect technique: 2½° on the upper centrals; 5° on the upper laterals; 2½° distal root tip on the upper cuspids; no angulation on the upper bicuspids. Lower centrals are angulated 1½°; 2½° on lower laterals; 2½° distal root tip on the lower cuspids; for lower bicuspids in non-extraction cases, we are using 2° of mesial root tip; in first bicuspid extraction cases we put 5° angulation on the second bicuspids; in second bicuspid extraction cases (Fig. 3), we put 2° of distal root on the first bicuspids.

In a lower anterior extraction case (Fig. 4), we will select lower incisor bands with the desired angulations that will overtip the remaining incisor roots into the extraction site. In a second bicuspid extraction case, we angulate the bracket or tube on the molar distal to the space to compensate and over-upright the molar, and maintain that position for the whole treatment.

Molar Banding

I band almost all of the lower second molars. When I do, I prefer a single Lewis bracket (Fig. 5) on the first molar because I feel it gives me more interbracket width and, therefore, more flexibility and more working room. Others may prefer a torqued twin bracket for the first molars, and both of these brackets will be available. There will also be convertible torqued twin brackets (Fig. 6) for those who plan to band second molars later on. If I am going to add a second molar band, I prefer to

take off the first molar band, exchange its tubes for a torqued Lewis bracket, and cement the two molar bands. Some orthodontists just leave the first molar tube and thread the archwire through the tubes on the first and second molars, and that is workable.

If I am going to band upper second molars, I use a torqued Lewis bracket on the upper first molar and cut off the mesial wing in order to preserve the rotation of the upper first molar. If you leave the mesial wing or use a twin bracket on the first molar when banding the upper second molar, you will lose rotation of the upper first molar, unless large lateral offset bends are placed in the archwire.

On the terminal maxillary molars you can use either a single rectangular tube or a combination tube. The combination tube has an .045 or .051 round tube for a facebow and rectangular tube with 6° of rotation plus 10° torque.

Archwires

I start most cases with an .016 round archwire. If one is accustomed to banding all the teeth at the start of treatment, a twisted wire would be a good initial archwire followed by the .016. I do not usually band all the teeth at one time. For example, in the upper arch I normally start by banding centrals, laterals and molars. This greatly increases the flexibility of the wire permitting greater tooth movements, active over a longer period of time, with smaller forces. This is why it is easy for me to start with an .016 wire.

The initial archwire is intended to rotate and untip and only use the amount of space in the extraction site that is necessary to get the rotations out. Molar stops are placed in this archwire to preserve the arch length, a most important point in anchorage preservation. Occasionally I will use vertical loops in the anterior region to help unravel teeth that are badly crowded and rotated. In extraction cases, I usually consolidate all six anteriors together on the .016 arch preparatory to retracting all six at once on a closing loop archwire.

The greatest inefficiency of this appliance is the initial archwire because, if the teeth are tipped or rotated quite a bit, a straight initial archwire will hang up on the wings. So, with severe rotations and tips you may have to offset the archwire so that it will con tact the wings, to take care of rotations first.

The correction of rotation and over rotation is one of the prettiest parts of this technique, due to the action of and the adjustability of the wings of the brackets. Sometimes you can't or don't get the bracket exactly where you want it. Rather than having to re place such a band, you can adjust the wing so that it will rotate the tooth into the position that you want. Another nice thing about rotation with these levers is that you can overrotate with the wings and then the wings hold the overrotation all through treatment. You don't rotate or overrotate and then lose it or have to make the adjustment in the next archwire. It is automatically preserved.

In extraction cases, the second archwire that I use is an .017 X .022 vertical loop arch (Fig. 7) which is used for closing the extraction spaces. In nonextraction cases, with no spaces to close,

there is no advantage to using the .017 X .022 arch and I use an .018 round archwire instead.

However, in extraction cases, the .017 X .022 is effective in closing the spaces all at one time. There is generally enough interbracket width between the bicuspid and molar, so that you can close an entire extraction site without having to make a new archwire if you are careful where you put your

tie back loops. Now, with torque built into each tube and bracket, permitting a flat rectangular archwire, no tie back loop is even necessary. The loops can be activated by pulling the wire through the tube and bending up the wire giving unlimited activation capability. I routinely see my patients at four-week intervals and activate the vertical loops the proverbial width of one thin dime.

Retracting Anteriors

I routinely take the six anterior teeth back at one time in extraction cases. If I need additional anchorage, then I have the patient wear a cervical or high pull facebow or a high pull or straight pull headgear off the arch wire, depending on the dictates of the particular case. If a patient is showing a lot of gum when they smile and I want to elevate as I retract, then I use a high pull headgear to the anteriors.

Ordinarily, I do not close spaces using Class II elastics. The pull of the Class II elastics makes it very difficult to keep the incisors up as they go back. If one felt he needed Class II elastics, I would certainly recommend a high pull headgear on the anteriors at the same time. In most cases, I finish with Class II elastics because I want to overdo the Class I correction. But, I don't use Class II elastics until all the spaces are closed and I am in the finishing arches.

On the .017 X .022 closing loop arch, you have to put gable bends at the vertical loops and a mild molar tip-back of about 10°. I do not usually have offset bends on the molars in the .017 X .022 arch, but I do place them in the final arch.

The final archwire is an .018 X .025 finishing wire (Fig. 8). This wire puts in the ultimate tips and torque, because of its closer tolerance to the size of the bracket slot. This is an ideal archwire with no loops, but with offset bends mesial to the molars and between the upper centrals and laterals (Fig. 9). What else may be built into this archwire may depend on what you see when you look into the mouth. If the incisors are a little long, if there is a little curve in the extraction site, you might want to counteract that with some reverse curve and tip-back in this archwire. Since I believe in overdoing all corrections, I tend to put molar rotations and a reverse curve in this archwire.

Here are some illustrations of the appliance on extracted teeth. Here are the upper and lower anteriors (Fig. 10).

Here are nonextraction bicuspids and the uprighting that you get with 2° angulation on them; and the angulation on the cuspids when they are tied into the .018 X .025 archwire. And here is an extraction bicuspid. It shows you the difference (Fig. 11).

Here is the complete set of extracted teeth banded and tied to preformed 0° torqued archwires

(Fig. 12). The brackets are angulated on the band material. The angulation is not built within the bracket, as the torque is.

On the upper first molar, the mesial wing is removed from the bracket when the second molar is banded. You do have to put an offset bend there to get good arch form. But, this permits you to control the rotation of an upper first molar when you want to band the second molar. Again, the reason for taking the mesial wing off is that, if you leave it, it will rotate the first molar on the mesial. In the lower arch when you band the second molar, the mesial wing is left on the lower first molar, because the lower first molar doesn't have to be rotated distally like the upper one does. Many times in an extraction case, in closing the spaces you will inadvertently let the lower first molar rotate mesially. Consequently you may want to cut the mesial wing off the bracket to enhance recovery. Many times I will not band the lower second molars until I have closed all the spaces.

For identification of the torque, there is a little scribe line. On upper centrals and laterals, that scribe line goes to the gingival. On the cuspids and on the posterior teeth where you have labial root torque, that line goes to the occlusal. When you are making bands indirectly, you have to be very careful about the direction of those lines, or you could be torquing in the wrong direction. You can't go wrong on the cuspid bands, because the bracket is offset incisally. Using band strips for bicuspid bands, you could put them on upside down. Using preforms, there is no way to be confused. They come in rights and lefts, already formed. Of course, you have to be careful not to switch left and right, or you will have the wrong system built in. Upper bicuspids are not angulated, so there is no problem about switching them. However, lower bicuspids are angulated and, therefore, left and right are different. Since the torque scribe lines for cuspids and bicuspids always go occlusally, it does not affect torque whether the bands are put on left or right. It is the angulation that is different. Two little weld marks-- two dots-- are used to show the direction of the angulation of the bracket on preforms.

Case Report

Here is a Class I case with about 6mm of crowding of the lower arch. He had a nice face even though the Holdaway ratio was 6:2 (Fig. 13). I took out lower second bicuspids and upper first bicuspids. I started this case on the lower arch, banding just first molars and first bicuspids, and

placing an .017 X .022 sectional closing arch on each side (Fig. 14).

After five months, I banded the upper teeth with the exception of bicuspids and placed an .016 archwire with stops set (Fig. 15).

I had to make mild adjustments in that upper .016 to reduce the force on the teeth and to insure the archwire didn't hang up on the rotation levers. I routinely put combination tubes on the upper molars. If I need them for facebow, I've got them. I did not plan to use facebow in this case, however.

Meanwhile, upper cuspids had drifted back somewhat by themselves. On the lower, we still have

the .017 .022 sectionals. They have been activated four times. Notice that the cuspids are following the first bicuspids without spacing. The second molars are also following the first molars forward. This is the advantage of using sectional arches on young people. The rest of the teeth in the arch tend to align themselves as room is made available. This greatly simplifies the mechanics.

Four weeks later, I cut out the upper .016 archwire and made it ideal by taking out those few adjustment bends (Fig. 16). I tied from cuspid to cuspid with elastic thread under the wings and under the archwire. I banded the bicuspids and retied the .016 archwire. The lower sectionals were activated. So, up to this point I have had one arch on the upper, removed and adjusted one time; and sectional arches on the lower, activated five times to bring the lower first bicuspids back.

Four weeks later, when the patient returned (Fig. 17), notice the improvement in the tipping of the bicuspid and cuspid. They have levelled out a bit. The six anteriors have been consolidated. Space is completely closed on the lower left, not yet on the lower right.

At this stage, I am ready to band the lower anteriors. Someone just starting on this technique, might want to take a ceph at this stage to check on the progress and on the uprighting of the anteriors. It would be reasonable to study at this point whether you need to put in a headgear and Class III mechanics to upright lower molars. I removed the lower sectional archwires, banded the six lower anteriors, and put in a .016 lower archwire (Fig. 18).

Meanwhile, I removed the upper .016 arch, ligated the six upper anterior teeth together with an .008 ligature wire under the wings, put in an .017 X .022 closing loop arch and activated it a little less than usual. I ligated the lower bicuspid and the molar together under the wings. If there is any space at all remaining to be closed anterior to the bicuspid, the bicuspid will tend to space mesially again, unless you ligate the bicuspid to the molar. I also put a little offset bend between the cuspid and lateral.

I used elastic thread to close that millimeter of space between the lower bicuspid and molar. The position of the upper tieback loop could have been farther mesially. That's some thing to be very careful about. It can cost you the time to make a whole new archwire if it is misplaced.

Four weeks later (Fig. 19), I removed the lower .016 archwire, took the bend out between the cuspid and bicuspid, made the archwire ideal, banded the lower second molars, changed the attachments on the first molars, and tied the archwire back in. I activated the upper closing loop about one millimeter.

Four weeks later ([img=20Fig. 20[/img]).I put in an ideal .018 round lower archwire. The reason I went to the .018 arch was because there was no space to close. So, in such a case, the sequence of arches is .016, .018, .018 X .025. Notice how the upper is improving. You can see the amount that I activate the closing loop arch. The legs of the loops are parallel when passive. Activation is about one millimeter.

Four weeks later (Fig. 21), I took out the .018 and put an ideal .018 X .025 archwire in the lower

arch and activated the upper arch. You can see the space closure going along nicely. No headgear or elastics have been used so far. From here on, the lower arch should require no further adjustments.

Now it is a matter of continuation of upper space closure, simply reactivating the upper arch. Notice the lateral offset, the tipback and bayonet bends on the molars, the cuspid eminences. There is a horizontal rotational bend in the molar area in addition to the tipback. You have to read that situation in the mouth and make your adjustment accordingly. See how the closing loops lie flat along the tissue. See how nicely the bite has opened. There has been a bit of a reverse curve that has helped that along. Basically, the bite opens a good deal when you level the lower arch with the second molars banded. The first molars and bicuspids are elevated to the level of the second molars and this wedges the jaws apart, thus opening the bite.

When I was ready to remove the bands (Fig. 22), both arches were ideal. The incisal edges of the upper central incisors have been recontoured for better esthetics. The posterior relationship was almost a Class III.

I try to remove the bands attached to the archwire. The upper bands are usually no problem (Fig. 23), but there are many times when I will remove the lower bands attached to the archwire up to the cuspids, cut the arch, and snip the lower anteriors off. I don't usually leave molar bands on. I want the teeth to settle in. I want to keep the extraction sites closed and close the band spaces.

When the bands were just removed (Fig. 24), there were the typical band spaces remaining to be closed. You see the hypertrophied gingival tissue. The bands were on the upper teeth for nine months, on the lower teeth for fourteen months, full banded for only seven months of that time. This is not an average time for treatment. Most cases take somewhat longer.

Retention

Retention in this case was maxillary and mandibular Hawley retainers. Maxillary retention is practically always a Hawley type retainer, regardless of the type case or extractions. However, I use three different retention approaches on the lower depending on the case:

Post-treatment Records

The post-treatment records (Fig. 26) give you the opportunity to evaluate for yourself the

effectiveness of building individual tooth positioning into the band and bracket rather than into the archwire.

Cephalometrically, the lower incisors went back about 3mm and continued to erupt 2-3mm. Upper incisors intruded 2mm and the jaws moved apart 6mm. This case turned out to be an easy one, with anchorage considerations being of a minimal nature. There was too much crowding to treat non-extraction, yet the lower incisors would be retracted too much with first bicuspid extractions. This is why lower second bicuspids were removed and no headgear was required. However, I do see those that are maximum anchorage cases. When I have one, the differences in treatment are that I will extract first bicuspids and add a headgear, cervical or high pull depending on the case, for which I have al ready made provision with my combination upper molar tubes. In addition the lower arch is set up and the extraction space closed with Class III elastics.

Conclusion

Treatment is not all hardware and this is not an automatic appliance. You must first diagnose and plan treatment to suit the individual situation, then modify the mechanics accordingly. This appliance does not dictate a treatment philosophy. Whether you extract or not, use headgear of any type or not, Class II or III mechanics or not-- all can be handled efficiently. You can treat any way that you want to. It is an excellent nonextraction appliance. It is an excellent extraction appliance. You can use any type of extraoral anchorage that you want. You can use palate splitting devices with it. This appliance has the versatility to let you put the teeth where you want to easily.

One of the greatest beauties of the New Torqued Appliance is the amount of time that the orthodontist has to expend to get from the beginning to the end of treatment. Usually, only three or four archwires are needed for the entire treatment. After the initial archwire, arch adjustments are minimal. Further, closing loop and finishing rectangular archwires can be purchased preformed. Reducing the number of archwires used, the amount of archwire manipulation, the number of times that archwires must be removed and tied in, all reduce the amount of operator time per case. This makes a significant contribution to efficiency in orthodontic treatment using the New Torqued Appliance.

(Hereby follow summaries of the New Torqued Appliance Torque and Angulation and Treatment Technique.)

END NOTES ON THE NEW TORQUED APPLIANCE TORQUE AND ANGULATION FOR INDIRECT OR DIRECT FABRICATION ON BAND STRIPS

non-extraction and on either right or left side.

NOTE-- These flexible Steiner wings cannot be adjusted with pliers; only with a special wing bender or they will break. Wing benders are available from Unitek Corporation .

END NOTES ON THE NEW TORQUED APPLIANCE TREATMENT TECHNIQUE

and upright, the adjustments are reduced until ideal arch form is attained.