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Endo tips    Better Endo    Endo abstracts    Endo discussions

  Tip edge and torquing

The opinions within this web page are not ours. Authors have been credited
for the individual posts and images where they are - Source: ESCO Digest

August 14, 2006
Please look at the enclosed attachments which show the spontaneous 
distal drifting the Tip-Edge bracket allows with NO FORCE applied. 
The first attachment is a sequential photo series of a cuspid 
replacement bimax case with a 2nd bi removed on the opposite side. 
(Tongue spurs subsequently added)  The 1st bi has moved into contact 
with the first molar which has remained stationary (held with a tip 
back bend; no force applied). The 2nd attachment is a lower
2nd bi extraction case showing Cl. I retraction of the lower anteriors.  
The freedom of movement inherent in the Tip-Edge bracket has allowed 
the right 1st bi to spontaneously outrun the retractive force with zero force
applied to it.

Why waste your anchorage retracting 1st biís when these teeth want to move naturally? In single arch extraction cases, why remove the robust and esthetically pleasing 1st bi and leave the patient with the unesthetic and often undersized 2nd bi? The answer seems to be that the friction inherent in the edgewise appliance forces you to do this. What a millstone friction has been for you in so many cases, causing you to resort to a wide variety of anchorage-enhancing strategies in instances where a much reduced force or no force is actually necessary. Proffit states that 100grams is needed to retract the cuspid and 100 grams is needed to overcome friction. Doesnít it just blow your mind to know that Tip-Edge can retract 6, 8 and even 10 teeth (in max. 1st molar extraction cases) with less force than edgewise needs just to overcome friction? Yes, self-ligating brackets can reduce this problem, but as long as your bracket has four corners, this handicap will continue to exist for you, not only for retraction, but for intrusion as well. Parkhouse has said that Tip-Edge is orthodonticsí best kept secret, and I believe this to be true. I challenge you to look at his book, Tip-Edge Orthodontics, and observe the great simplification of treatment that is available to you and your patients. For Charlie, Paul, Ernie and other Tip-Edgers: it certainly is tempting to consider finishing with 21x25 TMA, particularly since it facilitates wire transition from .020. I know youíre wary of this wireís ability to balance the bite-deepening effect of Stage 3. Of equal and perhaps even greater consideration is your ability to achieve ideal torque with 21x25. Though only incrementally smaller than the .022x.028, it will create a slight reduction in torque. In some of my school cases, I sometimes feel we barely achieve sufficient torque with 22x28, hence my concern with 21x25. Yes, I know itís only a nit, but one that can make a difference. A few words about Cl. II correction: in a growing individual with a good lower arch, traditional Tip-Edge works well. The mechanics hold the upper molars back, and growth does most of the work. Mulligan and others maintain that some distal tipping can be part of the equation, and I believe this to be true, while some have stated there may also be an increment of mandibular repositioning. In non-growers with a good lower arch, the removal of upper 2nd biís is much to be preferred. An alternative is Raleigh Williamís suggestion to remove upper 1st molars when the 3rds are well developed and positioned. (AJO: Oct. 1979). Regarding either Cl. I or Cl. II extraction cases, I believe the ideal pattern is the removal of upper 2nd biís and lower 1st biís; upper 2nd biís for the reasons stated above, lower 1st biís because the 2nd bi - 1st molar contact is much to be preferred to the alternative. Oftentimes the anatomy of the lower 1st bi resembles the cuspid and is a less than ideal neighbor for the molar. I have removed 4 second biís in minimum anchorage cases, but I think many of these cases would be better served by the removal of lower 1st biís, with the early application of lower braking mechanics. I welcome your further comments, suggestions and questions, particularly from my edgewise colleagues. - Mort Speck August 16, 2006 Rob, What a pleasant surprise to hear from you on this subject. I tried several years ago to arrange to spend a day with Dr.Meistrell at Columbia but his schedule and mine never seemed to match up. It would be interesting to hear from other clinicians on why more don't do Tip Edge. I have some personal ideas but I'll leave that for another day so as not to poison the discussion. I find the difficulty with Tip Edge is finishing. The TMA wire has reduced that problem because I can make small up and down or tip adjustments without having to go to a smaller wire. I really focus on bracket placement and use loupes as I'm sure others do and that is vital in Tip Edge. I will use a distal jet in two circumstances: 1. where I don't want any loss of lower anchorage and movement of the lower teeth. there is no free lunch so you do see the lower incisors come forward a little in most Tip Edge cases. 2. because of the finishing issue, if the case is mild class II, finishing is easier with regular straightwire once I've established the class I posterior occlusion. Here is another question for everyone: In many class II cases I've extracted upper 7s. Ever do that with Tip Edge in a nongrower? - charlie ruff Hi Charlie, I have been using Tip-Edge ever since I stepped foot out of the doors of Columbia U., amazing results over the years, Thanks Dr. Meistrell! I remember asking Malcolm Meistrell during my residency (1989) as he was showing me a Class II case with a 1/2 mile of overjet resolved with Tip-Edge/elastics, "why don't more orthodontists use this technique and why do they even bother with head gear, palatal arches, nance appl. etc for anchorage, it makes no sense to me?" He hesitated, shrugged his shoulders and said, " I don't know." I still don't know why orthodontists even bother with all of the techniques you mentioned. I suppose compliance with rubber band wear could be a factor but most kids with moderate to severe overjet want to look better so the motivational factor kicks in. Even if I do not get good elastic compliance, I use Mulligan mechanics with anchor bends mesial to the molars and e--link modules from molar hooks to anterior circles on wire. Resolves overjet and corrects class II with no compliance from patient needed. You mentioned that you use a distal jet in mild OJ cases. Why don't you use Tip-Edge also? I also use a .016 niti underlay and 21x25SS or TMA, works well! Kudos to the Keslings! - Rob Bruno, Manhasset, NY Sent: Thursday, August 24, 2006 3:20 AM Subject:tip edge tooth movement I have enjoyed reading the tip edge comments from this technique very articulate supporters. A couple thoughts from a 022 MBT guy and an observation on Mort's photos. (Very high quality photos I might add) I did some pure Begg during my training at Penn 10 (I hated those pins!) years ago and what I took away from my experience is that Begg practitioners watch and analyze every tooth position every visit. I suspect this approach is necessary in tip edge hence the thoughtful posts. (I have no experience with tip edge) Of course, all orthodontics should require thoughtful consideration of each tooth each visit. I am an ardent MBT orthodontist and the MBT system builds this careful consideration of tooth position into diagnosis, bracket placement, tip and torque values, anchorage considerations, light force mechanics and arch form selection and coordination (to maintain initial arch form). Because this attention to every tooth is built into the MBT system, and because the MBT system works within the known parameters of oral biology and also pays consideration to what we know tends to keep teeth stable, this is the system I use. I contrast that to what I see in many straight wire treatments, presentations, and transfer cases. There seems to be a pick the right arch/wire size form from the box, see what you get, don't mind the anchorage, get what you can with elastics, type of approach in many cases. This seem to have been taken to new heights by proponents of certain self ligating brackets that are claiming to have revolutionized bone biology as well by jiggling wire size and friction values. I think many straight wire folks put to much faith in the brackets and wires and not enough thought into the process. I enjoy the thoughtful articulate posts of the tip edge folks who seem to be dominating this discussion group of late but I must say that I am not convinced. Tip and torque must be recovered and I find it harder to tip and recover rather than get proper tip and then maintain. It is the same anchorage, I think my approach has fewer variables and surprises. Mort, your photo helps my point. In the case of the canine substitution 2nd bi extraction, I would venture to say that there has been very little bodily movement of the first bi, only tipping of the bi and molar. Palatal Rugae have been shown to be stable landmarks for evaluating tooth movement (part of my research project at Penn) and if you look at the tooth positions relative to the Rugae, it doesn't look like it has moved much, just tipped. This means the molar is also quite tipped and forward since the space is gone. This is OK if it is what you want, but I respectfully disagree that your photo shows that the extraction space has been closed by distal movement of the first bi. (I have reattached the photo I am talking about.) Again, I appreciate all of the good posts. I would like to see a more complete presentation of some tip edge cases but I never see them on the program at the AAO or in the table clinics. Where are you all? I am always open to a better way to do things but I think that MBT is a tough system to improve on. Are there any programs or table clinics at the Seattle AAO? I will make a point to seek them out. I look forward to the replies - John McDonald, Salem Oregon Disclaimer. I speak for Unitek on the MBT system as well as some other non clinical topics. Other than honorariums, I have no financial ties to Unitek Sent: Friday, August 25, 2006 3:20 AM Brad, Would you discuss how you transition out of 21 x 28 into 19 x25 braided for final finsihing. Do you ever find that as soon as you remove the heavy wire and auxiliaries that you see the teeth rotate at little. Not all the time but enough to make life less fun. any comments on finishing would be appreciated. - charlie ruff I also was trained at Columbia University like Dr. Bruno (Hi Bob!) in Edgewise, Begg and Tip-Edge by Dr. Meistrell and Graduated in 1991. Like most graduates, I went into practice using edgewise mechanics such as Jasper Jumpers, Herbst Appliances, Pendulums etc. I was most happiest with the Herbst in Class II corrections but did not enjoy all the hardware in my patient's mouths and the chair time cutting off the steel crowns. My cases also never quite had enough upper incisor torque and lower incisors were flared. Retention mandated fixed lower retainers. I knew there was an easier way and remembered how nicely my Class 2 Tip-Edge cases went in my residency. About 6 years ago , I switched back to Tip-Edge and have never regretted it. Thanks Dr. Meistrell and Columbia! I start my patients on the day of their banding with .016 wires and 2oz. Class II's attacking their overbite and overjet from Day 1 when they are motivated. I have never received a call that they are in pain. My cases typically use 4 sets of wires: .016,.022,.0215x.028 and 19x25 Braided. In Stage three we see patients every 8 to 12 weeks. My finished cases are superior to my edgewise by having nice upper incisor torque and lower incisor labial root torque and distal root tip. My staff enjoys the technique as well as wire changes are easier with the interbracket space and not having to cement in bulky devices. I also like the savings in lab costs. In regards to the new plus ceramic bracket, I try to avoid them, but have not had bases delaminate. This is one of the smallest ceramics on the market which makes it nice. In regards to other comments about extractions, I have extracted upper 6's in Class II nongrowers with a good lower arch (no deep curve of spee or crowding). I have also extracted all 7's which works great because the slots allow everything to tip distally. I have also extracted lower 6's in Class III cases with great results. I also agree about removing the 5's in class II cases. I really enjoy the technique and the esthetics of the small brackets and like others in this discussion do not understand why more orthodontists are not trying Tip-Edge - Regards, Bradley Nirenblatt, D.M.D. Date: Thu, 7 Sep 2006 John, To answer your question, Dr Parkhouse gives a course once a year on TipEdge. Because of all the chatter, I will attend a future course. The next one is in October 2006 so I will probably attend the following one. I tried Tip Edge before the underlay wire and I could not get the torque on the U12 that I wanted. Maybe I should say that I played with TipEdge. I was also a MBT at one time (for many years) and I have read the manual. I still use MBT techniques from time to time but I have converted over to the frictionless side (sine 1998). I have found that you can combine techniques and principles and do not believe everything that you hear. It will always be the practitioner and not the technique that will determine the case outcome( for the most part) - Roy King Date: Wed, 6 Sep 2006 16:57:16 -0400 Sub: Tip-Edge Torque Illustration Richard Parkhouse (Tip-Edge Orthodontics, Mosby) generously provided me with the enclosed photos which illustrate the torquing and uprighting mechanism of the Tip-Edge appliance. The first slide shows the ni-ti wire in the deep tunnel prior to the placement of the .0215 X.028 base wire. The design of the bracket with its cut-out corners allows the placement of the full size wire despite the tipping of the teeth. It is the uprighting of the teeth which causes the programmed surfaces of the bracket to close down on the rectangular wire which affects the tip and torque. For the first time in the history of orthodontic there is 100% expression of the programmed torque. Because of the play in the traditional edgewise sytem, that technique compensates by increasing the torque prescription, which apparently works well. For those of you who might be interested, I recently learned that Parkhouse will be lecturing at the TP Tip-Edge course giiven On Oct. 26 - 28. Once again, for the record, I have no commercial relationship with TP; only great appreciation for the Plus bracket and Tip-Edge technique, and it's inventor Peter Kesling. - Mark Speck Date: Thu, 7 Sep 2006 Richard Parkhouse (Tip-Edge Orthodontics, Mosby) generously provided me with the enclosed photos which illustrate the torquing and uprighting mechanism of the Tip-Edge appliance. The first slide shows the ni-ti wire in the deep tunnel prior to the placement of the .0215 X.028 base wire. The design of the bracket with its cut-out corners allows the placement of the full size wire despite the tipping of the teeth. It is the uprighting of the teeth which causes the programmed surfaces of the bracket to close down on the rectangular wire which affects the tip and torque. For the first time in the history of orthodontic there is 100% expression of the programmed torque. Because of the play in the traditional edgewise system, that technique compensates by increasing the torque prescription, which apparently works well. For those of you who might be interested, I recently learned that Parkhouse will be lecturing at the TP Tip-Edge course giiven On Oct. 26 - 28. Once again, for the record, I have no commercial relationship with TP; only great appreciation for the Plus bracket and Tip-Edge technique, and it's inventor Peter Kesling. - Mort Speck

Date: Wed, 13 Sep 2006 I have been following this discussion, but I must say I am also puzzled by the biomechanics of this appliance. In physics, moments in one plane are independent of moments in the other perpendicular planes (cannot cause a rotation in other planes). I do not see how uprighting of the teeth (rotation parallel to the buccal face) may lead to increased torque expression. Apparently this bracket design has increased play in 2nd order, but the dimensions are the same in 3rd order. So what makes it different from a regular edgewise bracket in 3rd order? (If you rotate a car tire wrench in one plane can you observe rotation in other planes?). The first impression I had was that torque with a "round wire" was referring to the old 60's Begg torque accessory. Not sure if the tip-edge guys (perhaps it could also be called Begg 2.0) still use this mechanism. Simple loops placed on the anterior region of a round archwire (loops bent on the same plane of the archwire, not perpendicular like we do for alignment) make the posterior region of the torquing auxiliary archwire go up or down posteriorly. When we make the loops parallel to the buccal surface of the anterior teeth, the posterior wire goes up or down. When the posterior extension is brought to the posterior bracket level, this loop archwire causes " torque" (3rd order moment) on the anterior teeth. You need to tie them back to restrain the rotation at the brackets, otherwise hey will just tip around a point close to the Cres. This mechanism has a few mechanical problems (soft wire deforms in second order due to the anterior and posterior vertical forces being in different planes- it's actually a 3D beam problem), but there are some ways around it even from the tip edge point of view (like using a stiffer round wire inside a second horizontal slot). - Rodrigo F. Viecilli De: "The Electronic Study Club for Orthodontics" Data: Mon, 18 Sep 2006 17:54:06 +0200 Assunto: Torquing with TipEdge Dear Dr. Viecelli and to the rest of you wondering about how you can torque with an .016 nitinol in tip edge. After stage II in tip edge treatment the incisors are not only tipped lingual but also distally. The .016 upright wire will correct this second order tipping and gradually force the rectangular wire from the .028 slot into the .025 slot. Included you will find the explanation how this works (taken from the fifth edition of the "TIP-EDGE-GUIDE" by Peter C. Kesling, D.D.S.. Sc.D.). Sometimes you still need to place an auxiliary torquing spring. Marco TribÚ, Zuerich

Hello Dr. Tribo Thanks a lot for your figure. If you look at it closely, you will observe that from the beginning to the end there are still 2 contact points for the 3rd order expression of the archwire on the slot (one for the force pointing to the gingiva and one for the force pointing to the incisal). Nothing changes in 3rd order from the first to last picture, from the Statics point of view. You do not get an increase in torque by getting additional contact points- this assumption is a mechanical fallacy. Why? Because more contact points will simply divide the force into a "load" which is simply that force distributed along all contact points. There's a similar fallacy related to friction- some people think more area of contact means more friction. It doesn't matter. The total force magnitude is still the same. You will realize that this idea is mechanically impossible if you think of a second order moment vector perpendicular to the third order moment vector. They do not affect each other. I don't know about other schools, but I don't think any of our basic orthodontic biomechanics students here in Indiana or any engineer would buy this idea. Rotations in second order (couple of forces in the frontal plane) do not cause rotations in third order (couple of forces in the sagittal plane). If you have a couple of forces (opposite sense, same magnitude) , and one acts on the mesial of the bracket, and the other on the distal, the only situation where this would cause a third order moment is if there is a distance between these forces antero-posteriorly. From another perspective, a resultant extrusive or intrusive force on the bracket, if far from the center of resistance, can change the inclination of the tooth in 3rd order and reduce (or increase) the play between the slot and the archwire. But this can be done using any bracket (with an overlay intrusion or extrusion base arch), not only tip edge. Maybe what happened to the person that wrote the book is that he/she had such a resultant force during 2nd order tipping and generalized it to all cases. I am sure tip edge has some good points, but this is certainly not one of them. Best regards, - R Date: Mon, 18 Sep 2006 22:17 I want to thank John MacDonald for keeping me honest. (My resident, who is treating the case, appreciated your comment about the quality of the photos.) Itís hard to imagine that there has been much mesial movement of the molars when compared to the rugae since the molars were under a tip-back moment and no protraction force was applied. (Does rugae position change when anterior teeth are protracted?) Regardless, donít lose sight of the fact that the bicuspid moved distally on its own with no force applied. Yes, of course it tipped as all teeth do initially in this technique. That is what makes it possible to simultaneously retract six, eight and even ten teeth with the lightest of forces, and at the same time affect bite opening. Why spend your anchorage assets retracting teeth that will readily move if you will only let them? There is no doubt you pay the anchorage piper in the torquing and uprighting stage of Tip-Edge, but there is no question that total anchorage requirements are less than any edgewise system. This would be difficult to prove scientifically, but as Parkhouse states, the clinical evidence is unarguable. I was giving this message to a group of residents when I was challenged by a young man whose father was an ardent edgewise practitioner. In response, I asked the group to tell me who among them was treating a maximum anchorage edgewise extraction case without using either headgear, banded 2nd molars, a transpalatal arch or palatal button, or any combination. Not one resident raised his or her hand and I rested my case. I can ask the same question of you, my edgewise colleagues. It is in the really difficult cases that this technique shines. But John had it right when he wrote that you have to analyze every tooth position at every visit. As with any technique, problems do arise. This is particularly true with Tip-Edge because the teeth are free to move so rapidly that the operator must be continually alert. I respect what John has written about MBT; the results the authors show in their book are outstanding. But I feel similar results can be achieved without resorting to anchorage auxiliaries. It is my view and that of my Tip-Edge colleagues that the 2nd order finishing movements that are affected with the very first wire belong at the end of treatment, not at the start. And it is this action, as well as the apex first retraction of teeth that straight wire dictates, that readily depletes your anchorage bank account and necessitates the use of auxiliaries in those tough cases. The teeth look a lot neater during the course of straight wire treatment as compared to the untidy appearance (albeit temporary) of the Tip-Edge case, where the crowns are free to move along the path of least resistance. If this early control is important to you, than Tip-Edge is not your cup of tea. Dr. Rodrigo Viecilli is right. There is little difference in the Tip-Edge bracket in the 3rd order since two of the opposing corners have a straight wire design. The difference lies in how the torque is achieved. In straight wire, obviously the program in the bracket affects a twist in the wire that in turn reacts to torque the incisor. In Tip-Edge, the rectangular arch wire is a neutral and stable platform upon which the programmed portion of the bracket closes down to the torque. I had to smile when he referred to Tip-Edge as Begg 2.0. Thatís like my calling his late model auto a Model T 2.0. Incidentally, the AAO library, which is a wonderful and free resource, has at least one copy of the Parkhouse text available to anyone interested in borrowing it. - Mort Speck, Belmont, MA From Paul M Thomas Date: September 20, 2006 In reference to the ongoing discussion regarding Tip-Edge and torquing, I would offer the following comment as well. Tip-Edge Plus retains the ability to use the Sidewinder springs when desired as an alternative to threading the deep tunnel archwire. These can assist significantly in anchorage preservation when necessary (as Richard would say) to "put on the brakes". Of course it may take a bit more thought than threading the tunnel in regards to counterclockwise versus clockwise springs, but then isn't orthodontics meant to involve a bit of thought? :o) For all-out anchorage cases, we have mixed and matched being "equal opportunity employers". Tip-Edge works nicely with the temporary anchorage devices or orthodontic bone anchors (attached). The light forces and ability to tip/upright the teeth reduces some of the load on the anchor screws and decreases the likelihood of failure. I can speak out of both sides of my mouth since my grad clinic supervision cases are divided roughly 50/50 between MBT and Tip-Edge. We are fortunate to have Richard still be willing to provide a yearly Tip-Edge course for our grads to introduce them to a technique which works wonders with some of the Brit "whopper" class II malocclusions. I admit that Richard is a bit of a cheerleader for the technique which may foster a bit of the "us and them" mentality, but he is enthusiastic (passionate, perhaps) about life in general.... whether poodling along at 4mph in his narrowboat or at 140mph on his motorbike.

I personally have enjoyed seeing the grads have the experience with each system. Both produce excellent results when used as intended. Paul M Thomas Senior Research Fellow Departments of Orthodontics and Oral and Maxillofacial Surgery London WC1X 8LD Wednesday, September 20, 2006 4:52 AM Another possibility of what the Tip Edge colleagues may be referring to is this: although moments are independent, the rotation of a body in one plane can cause reaction forces that are not in the same plane, which, in turn, cause rotation in another plane. In 2D, of course. this is not possible, but it is in 3D. For instance, let's consider an upper right incisor. If there is a buccal crown twist in the archwire inside an its bracket that does not express itself as 3rd order moment because of play, and someone applies a mesial crown tipping moment to it, the two reaction forces in the bracket slot will be separated by an antero-posterior distance. What this means is that now we are applying both a second order and third order moment at the same time. Now, it's not the round wire doing it. It's the rectangular wire doing it as a reaction to the changed position of the bracket. The round wire continues delivering only a second order moment, it doesn't "torque" the teeth. The third order couple that we just described will tend to move the crown buccally. If you apply a distal tipping moment to the crown, the same happens, and a couple that tips the molar bucally will appear created by the rectangular archwire. The reason is that the anterior and posterior edges of the archwire have a height discrepancy when it is twisted. So, when the tooth tips in 2nd order, at a certain point in time it contacts the posterior edge of the archwire distally, and the anterior edge mesially, or vice-versa. In our everyday mechanics, this happens during common rectangular archwire leveling with any bracket- not just the tip edge bracket. In a tip edge bracket, this has to be done separately, with the uprighting auxiliary (or round wire), because they increased the 2nd order play to improve leveling efficiency. The effect and "torque gain or loss" is the same got by the regular edgewise bracket, unless you apply more 2nd order moment than you should to "overcorrect" the 2nd order position). The regular edgewise bracket does both at the same time. I see this more as a "lack of control" of 3D archwire leveling than as an general advantage, because the " twists" along the rectangular archwire vary greatly during leveling. In addition, from the same perspective, it is important to know that the opposite is also true: third order moments can change 2nd order positions by means of the same mechanism. When you initially level with tip edge, you have the advantage of having more second order play, so you miss some of the torque that you could get with a regular edgewise bracket. In the end, it's the same "torquing" expression of the regular edgewise, after the uprighting springs. If there is another argument I missed in this matter, please let me know. - r "I dream of a world where orthodontists will care more learning biomechanics than purchasing a new bracket." Old Chinese Proverb

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