State of the Art Orthodontics Self Ligating Appliances,

Miniscrews and Second Molars Extraction

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ISBN 9780723436539

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 Preface

Current technological advances have had a major that patients take into consideration when deciding
impact on contemporary orthodontics, allowing the whether or not to undergo orthodontic treatment.
clinician to provide quality treatment with favorable
esthetic results in a shorter time period. Indeed, The development of the metal SmartClip™ self-ligating
patients are increasingly seeking orthodontic appliance led to the possibility of developing the
treatment that does not negatively affect the facial Clarity™ SL Self-Ligating Appliance. This appliance
esthetics. Thus, clinicians need to have sound scientific features the same characteristics as the SmartClip™
knowledge and appropriate technology at hand to be self-ligating metal appliance, however, it also fulfills
able to offer optimal treatment to each patient. the esthetical needs of patients.

The use of esthetic, low-friction orthodontic appliances Finally, the book also discusses the concept of second
and orthodontic miniscrews allows faster and more molar extractions in orthodontic treatment. This is a
efficient treatment with a reduced risk of the side useful option in carefully selected patients in whom
effects of conventional orthodontic mechanics and the erupting third molars would eventually be a good
tissue damage caused by the orthodontic tooth substitute for the second molars extracted for
movement. These appliances also address the issue of orthodontic purposes.
lack of cooperation on the part of patients with regard
to use of headgear and other traditional intraoral Thus this book presents a treatment philosophy based
anchorage devices, when treating Class II and Class III on use of esthetic self-ligating appliances and
malocclusions or severe crowding. Both adolescent orthodontic miniscrews for anchorage, and treatment
and adult patients often refuse to wear these with second molar extraction. All these factors allow
appliances as they are not considered esthetic. This the clinician to provide orthodontic treatment with
book emphasizes the importance of facial esthetics more predictable results and efficient sliding
during orthodontic treatment by describing intraoral biomechanics with the application of low force levels
anchorage systems that help eliminate the and more favorable biological responses.
requirement for headgear and also diagnosis,
treatment planning and orthodontic biomechanics Hugo Trevisi
with second molar extractions. All these are key issues Reginaldo Trevisi Zanelato
 Acknowledgments

Firstly, we wish to thank our wives and our children Our sincere thanks to our friend Dr Lars Christensen,
for their care, understanding and support while we from England, for his support in revising this book.
were writing this book. To them, we reattribute with Lars’s work made this book didactic and easy to
love all these years of being together. comprehend.

We also want to thank Dr Adriano T. Zanelato, Dr We also would like to acknowledge our friend David
André T. Zanelato, Dr Renata Trevisi, Dr Edson Alves, Solid, from Monrovia, USA, for his final revision of the
Dr Cristina Ferro and Dr Fernando Bonini from Brazil, book. Our sincere thanks to Barbara Simmons, Alison
as thanks to their support in daily practice, we were Taylor and Nancy Arnott from Elsevier, and Lotika
able to collect the scientific material required to write Singha. Thank you for your trust.
this book.
Portions of the text and graphic images © 3M. Used
We acknowledge and very much appreciate the with permission.
translation work of Michelle Trevisi de Araujo.
CHAPTER 1 Low-friction esthetic brackets:
the Clarity™ SL Self-Ligating
Appliance System

Introduction 2 Space closure 18

Characteristics of the appliance 3 Finishing and detailing 20
The Clarity™ SL Self-Ligating Appliance System
prescription 4 Clarity™ SL Self-Ligating Appliance bracket removal 23
Mesiodistal angulation 5 References 26
Inclination (torque) 6 Clinical case 1 27
In-out 7 Clinical case 2 50
Slot depth 8

Sliding mechanics with the Clarity™ SL Self-Ligating

Appliance 10
Aligning 11
Leveling 13
2 STATE-OF-THE-ART ORTHODONTICS

Introduction treatment. These benefits aimed to fulfill the

requirements of an esthetic appliance as could be
A desire for orthodontic treatment that does not approved by the orthodontist: that is, it has to allow
adversely affect facial esthetics, both during and after good torque, tip and rotational control, and be
treatment, is increasingly seen in the orthodontic comfortable for the patient. It also has to be easy to
practice. The first esthetic appliances date back to the place and to remove, exhibit reliable bond strength,
1970s and were manufactured in plastic.1–3 and provide a good end result of the orthodontic
treatment.
The Clarity™ appliance, which was released in 1996,
had distinctly different characteristics from the other While there are several obvious advantages of esthetic
appliances available at that time. The polycrystalline appliances, there are also some disadvantages. One
ceramic Clarity™ brackets featured a metal slot, and major issue is the change in color of the elastic
this bracket design provided excellent facial esthetics modules used to hold the archwire in the bracket slot,
with very good sliding biomechanics and precise which is caused by poor oral hygiene or the eating
tridimensional control of teeth during orthodontic habits of the patient (Figs 1.1, 1.2 & 1.3). The patients

Fig. 1.1

Fig. 1.2 Fig. 1.3

Figs 1.1, 1.2 & 1.3 Change in color of the elastic modules used with conventional appliances, worsening facial esthetics during the course of orthodontic
treatment.
 CHAPTER ONE
Low-friction esthetic brackets: the Clarity™ SL Self-Ligating Appliance System 3

who most often experience this problem are those who Characteristics of the appliance
drink coffee, tea, red wine, etc. on a frequent basis, as
well as patients who smoke. These patients have to The Clarity™ SL Self-Ligating Appliance System,
come back to the office more often simply for new which is based on the original concept of the straight-
elastic modules in an effort to maintain the esthetics of wire appliance, features mid-size, rhomboidal brackets
their appliance. with twin wings. It is a passive bracket system – the
archwire is able to slide freely in the bracket slot, with
When the SmartClip™ Self-Ligating Appliance was less binding between the wire and the bracket slot
released in 2004, the possibility of having a Clarity- when using undersized wires.
style appliance featuring the characteristics of a
self-ligating appliance became apparent. However, this The Clarity™ SL Self-Ligating bracket is composed of
appliance would not only have to have the same three parts that are manufactured separately: the
characteristics as the metal4 self-ligating appliance, ceramic bracket body, the metal slot and the Nitinol
but would also have to address the needs of patients clips (Fig. 1.4). The bracket body is manufactured in
who were looking for a more esthetic smile during the
treatment. In 2007, new advances in technology
made it possible to manufacture the Clarity™ SL
Self-Ligating Appliance. It featured the same
characteristics as the conventional Clarity™
appliance, e.g. a ceramic bracket with a metal slot and
a unique debonding mechanism. The Clarity™ SL
Self-Ligating Appliance utilizes the same
manufacturing technology as the metal self-ligating
appliance, with Nitinol clips on the mesial and the
distal bracket wings.

Fig. 1.4 Clarity™ SL Self-Ligating Appliance bracket: note the ceramic

bracket body, metal slot and the mesial and distal clips.

ceramics and the bracket slot is produced in metal and

inserted in the bracket base. The Nitinol clips are laser
cut and pressed onto the mesial and the distal sides of
the bracket. The clips are designed to be fatigue
resistant while both engaging and removing
archwires. As mentioned above, the bracket system
offers the same features as the conventional appliance,
enabling the use of elastic chains, metal and elastic
ligatures and all the other attachments that are
usually used with the conventional approach.
4 STATE-OF-THE-ART ORTHODONTICS

The Clarity™ SL Self-Ligating archwire in the .022/.028 bracket slot. This is usually
Appliance System prescription the last archwire to be used in treatment. The basic
orthodontic concepts underlying the use of the
Clarity™ SL Self-Ligating Appliance System are the
As mentioned above, the Clarity™ SL Self-Ligating
same as those for the SmartClip™ Self-Ligating
Appliance System features a bracket designed for
Appliance System (Figs 1.5, 1.6 & 1.7).
sliding mechanics, that is when using a .019/.025

Fig. 1.5

Fig. 1.6 Fig. 1.7

Figs 1.5, 1.6 & 1.7 Clarity™ SL Self-Ligating brackets in the upper arch and the SmartClip™ Self-Ligating Appliance in the lower arch.
 CHAPTER ONE
Low-friction esthetic brackets: the Clarity™ SL Self-Ligating Appliance System 5

Mesiodistal angulation and the individualized bracket positioning system

prevents undesirable proclination of the anterior teeth,
The basic Clarity™ SL bracket design is the same as increased overbite and anchorage loss during the
the conventional brackets – rhomboidal brackets with aligning and leveling stages of the orthodontic
built-in angulation. The rhomboidal shape makes treatment. The individual bracket positioning system
bracket positioning easier, along with the use of the allows positioning of the teeth with due regard to their
individualized bracket positioning system4–6 (Figs 1.8, natural morphology, thus bringing stability to the
1.9 & 1.10). occlusion that is attained at the end of the treatment.

The rhomboidal bracket system used with the MBT™

Versatile + Appliance System orthodontic prescription

4º

Fig. 1.9 The rhomboidal Clarity™ SL

brackets. The bracket is positioned on the
Fig. 1.8 The Clarity™ SL appliance features rhomboidal-shape brackets. facial surface of the clinical crown using
This bracket system favors accurate bracket positioning on the facial the individual bracket positioning line as a
surface of each tooth. reference.

4º 8º 8º 0º 0º

0º 0º 3º 2º 2º
Fig. 1.10 The built-in angulations in the Clarity™ SL Self-Ligating upper and lower brackets.
6 STATE-OF-THE-ART ORTHODONTICS

Inclination (torque) base and the bracket slot. A metal slot imparts greater
strength to the bracket and allows full torque
A highly sophisticated manufacturing process allows expression. Furthermore, the metal slot facilitates good
the addition of a metal slot into the ceramic bracket sliding of the archwire during the orthodontic
body of the Clarity™ SL bracket. The reliability of an treatment by reducing friction.7,8 The Clarity™ SL
orthodontic appliance depends on the degree of appliance also features built-in torque in the metal
expression of the torque that is built into the bracket slots (Fig. 1.11).

17º 10º 0º –7º –7º

–6º –6º 0º –12º –17º

Fig. 1.11 Profile view of the upper and lower Clarity™ SL brackets showing the torque prescriptions.
 CHAPTER ONE
Low-friction esthetic brackets: the Clarity™ SL Self-Ligating Appliance System 7

In-out buccal-occlusal and lingual-occlusal marginal ridges

depends on good coordination between the upper and
From the horizontal aspect, the functional harmony lower arches,5–8 as well as the in-out prescription of
of the orthodontically created occlusion is determined the orthodontic appliance (Figs 1.12 & 1.13). The
by the in-out built into the appliance, the shapes of Clarity™ SL Self-Ligating brackets have been
the archwires used, and the coordination achieved manufactured with this relationship in mind, which
between the upper and the lower dental arches. allows the simultaneous use of conventional
The interarch relationships, including the anterior appliances and the SmartClip Self-Ligating appliance
and the canine guidance, and the posterior in the same patient during orthodontic treatment (see
relationship between the centric cusps and the Figs 1.5, 1.6 & 1.7).

U Cent 0.044 U Cent 0.044

U Lat 0.058 U Lat 0.058
U Can 0.030 U Can 0.030

U Pre 1 0.036 U Pre 1 0.036

U Pre 2 0.036 U Pre 2 0.036

U Mol 1 0.040 U Mol 1 0.040

Fig. 1.12 Occlusal view of the upper arch, showing the in-out prescription
of the Clarity™ SL Self-Ligating brackets.

L Mol 1 0.030 L Mol 1 0.030

L Pre 2 0.033 L Pre 2 0.033

L Pre 1 0.029 L Pre 1 0.029

L Can 0.029 L Can 0.029

L Ant 2 0.060 L Ant 1 0.060 Fig. 1.13 Occlusal view of the lower arch, showing the in-out prescription
L Ant 1 0.060 L Ant 1 0.060 of the Clarity™ SL Self-Ligating brackets.
8 STATE-OF-THE-ART ORTHODONTICS

Slot depth stages of treatment (Figs 1.14, 1.15 & 1.16).9,10 These
stages are completed when the bracket slot is fully
As mentioned above, the Clarity™ SL Self-Ligating filled by the orthodontic archwire in the horizontal
appliance is a passive appliance, that is, the clip does plane. The .019/.025 rectangular archwire (Fig. 1.17)
not exert active pressure on the archwire, unless it is or an .016 archwire overlapping the .014 round
required, e.g. to correct rotations. This allows the use Nitinol archwire should be engaged on the same visit
of lower forces during the alignment and the leveling (see Figs 1.34, 1.35 & 1.36 below).

Fig. 1.14

Fig. 1.15 Fig. 1.16

Figs 1.14, 1.15 & 1.16 Initiating the aligning stage with a .014 round Nitinol superelastic wire in the upper arch.
 CHAPTER ONE
Low-friction esthetic brackets: the Clarity™ SL Self-Ligating Appliance System 9

The depth of the Clarity™ SL Self-Ligating appliance

slot measures .0270 inches between the clip and the
bottom of the bracket slot in the lower incisors, and
.0275 inches in the remaining teeth. This has been
Fig. 1.17 Occlusal view of the upper arch with a .019/.025 rectangular done in order to have improved rotational control at
Nitinol archwire in place. Note the good fill of the slot from the horizontal
aspect.
the beginning of treatment (Figs 1.18 & 1.19).

.0275 .0275 .0275 .0275 .0275

Fig. 1.18

.0270 .0270 .0275 .0275 .0275

Fig. 1.19

Figs 1.18 & 1.19 Profile views showing the slot-depth between the clip and the bottom of the bracket slot of both upper and lower Clarity™ SL Self-Ligating
brackets. Lower incisor brackets have .0270 inch slot depth.
10 STATE-OF-THE-ART ORTHODONTICS

Sliding mechanics with the Clarity™ SL When the orthodontic archwire is allowed to slide
Self-Ligating Appliance freely within the bracket slot in the aligning stages,
the masticatory and the muscle forces work in
harmony with the applied biomechanics with low
The principle of sliding mechanics4,5,11,12 can be
force levels, and thus a favorable biological response
applied without any need for compromise when using
(Figs 1.20 & 1.21).
the Clarity™ SL Self-Ligating brackets. The metal slot
allows precise accomplishment of aligning, leveling,
space closure, and finishing and detailing.

Fig. 1.20 Fig. 1.21

Figs 1.20 & 1.21 Clarity™ SL Self-Ligating Appliance with a .014 round Nitinol superelastic archwire after the initiation of the rotational and the labiolingual
corrections.
 CHAPTER ONE
Low-friction esthetic brackets: the Clarity™ SL Self-Ligating Appliance System 11

Aligning used regardless of the case being extraction or non-

extraction. A .022/.028 bracket provides greater
Alignment is the first stage of orthodontic treatment flexibility to .014 archwires, enabling perfect archwire
and, depending on the severity of crowding, a .014 engagement and disengagement using the Nitinol clips
round Nitinol or other superelastic archwire can be (Figs 1.22, 1.23 & 1.24).

Fig. 1.22

Fig. 1.23 Fig. 1.24

Figs 1.22, 1.23 & 1.24 The .022/.028 Clarity™ SL Self-Ligating Appliance in the upper arch and SmartClip™ Self-Ligating Appliance in the lower arch. An .014
round Nitinol superelastic archwire has been engaged in both the upper and lower dental arches, initiating the alignment stage.