Appliance specifications variations and versatility

Introduction 27

Design features of a modern bracket system 28

Range of brackets 28

Rhomboidal shape 29

Torque in base - the CAD factor 30

In-oul specification 31

Expression of in-out 31 Upper second premolars 31

Tip specification 32

Expression of tip 32

Torque specification 33

Expression of torque 33 Incisor torque 34 Canine torque 36

Upper premolar and molar torque 37 Lower premolar and molar torque 38

The versatility of the bracket system 39

Aspects of versatility 39

Palatally displaced upper lateral incisors 40

Three torque options for the upper canines 44

Three torque options for the lower canines 44

When should the three canine options be used? 44

Interchangeable lower incisor brackets 48

Interchangeable upper premolar brackets 49

Use of upper second molar tubes on first molars in non-HG cases 50

Use of lower second molar tubes on upper molars in Class II molar relationships 51

Additional bracket and lube options 52

Bracket for small upper second premolars 52

Lower second premolar tubes 52

Lower first molar non-convertible tubes 53

Lower first molar double tube and upper first molar triple tube attachments 53

Bondable mini second molar lubes 54

INTRODUCTION

It has been said that medical and dental treatment is based equally on science, tradition, and clinical experience. When the original SWA became available in 1072, it was based 011 science, but included many of the traditional features of Siamese edgewise brackets. It was radically new and therefore there was no input from clinical experience. Andrews' had measured 120 non-orthodontic normal cases and then used the data, with some changes, to produce a bracket system.

It is almost 30 years since the original SWA was released. The science and tradition which went into the original design are now balanced by a wealth of clinical experience. The authors have also re-examined Andrews' original findings, and introduced additional research input from Japanese sources,2,3 to update the scientific input.

From an early stage, the authors avoided the traditional heavy edgewise forces and they developed a treatment system based 011 sliding mechanics and light continuous forces, which has seen widespread acceptance. They developed a third generation of brackets to follow the Andrews (first-generation) and Roth (second-generation) appliances, on the basis that the proven mechanics and force levels should determine the design of the new bracket system, and not vice versa.

The MBT™ Versatile-)- bracket system maintains all that was best in the original design, but at the same time a range of improvements and specification changes have been introduced to overcome the clinical shortcomings. It is based on a balanced mix of science, tradition, and experience. The appliance is recommended as a modern version of the preadjusted bracket system for use with light continuous forces, lacebacks, and bendbacks. It was designed to work ideally with sliding mechanics.

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Dental Treament With Restraing
Medical and dental treament
Mid Size Metal Ortho Bracket

Fig. 2.2 Mid-size metal brackets.

Pre Adjusted Appliance

Fig. 2.3 Esthetic Clarity™ brackets.

Fig. 2.1 Standard size metal brackets.

Fig. 2.3 Esthetic Clarity™ brackets.

DESIGN FEATURES OF A MODERN BRACKET SYSTEM

Range of brackets

The baseline of expectation concerning orthodontic brackets has risen considerably since the original SWA was released in the 1970s. The modern orthodontist expects to have three main bracket systems available to meet the needs of a typical caseload:

• Esthetic brackets - these will be needed for older patients, where a metal appearance is not acceptable (Fig. 2.3).

Standard size metal brackets - where control is the main requirement (Fig. 2.1).

Mid-size metal brackets - these give less control, but are useful for cases with average to small teeth, where there is poor oral hygiene, or where control needs are modest (Fig. 2.2). '

Fig. 2.1 Standard size metal brackets.

These are general developments in orthodontic bracket technology. They are not specific to the preadjusted system, but they are changes which were incorporated into the new concept.

The original i.d. system of dots and dashes has been superseded by laser numbering of standard size metal brackets (Figs 2.1, 2.4 & 2.5). This feature cannot be carried through into mid-size brackets, owing to their smaller size, and it is technically not possible with clear brackets. So for these groups of brackets, a more conventional i.d. system of colored dots continues to be used.

Fig. 2.2 Mid-size metal brackets.

Rhomboidal shape

The original rectangular shape of the standard metal SWA (Fig. 2.4) has been superseded by the rhomboidal form (Fig. 2.5).

This reduces the bulk of each bracket and allows reference lines in both the horizontal and the vertical planes, thereby assisting accuracy of bracket placement.

Pre Adjusted AppliancePre Adjusted Appliance

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Pre Adjusted Appliance
Fig. 2.4 The original standard metal SWA brackets were rectangular in shape, and the i.d. system was based on dots in the upper arch and dashes in the lower arch.

Fig. 2.5 Brackets of a rhomboidal shape have reduced bulk and there is coordination of perspective lines through only two planes, which assists in accuracy of bracket placement.

Torque in base - the computer-aided design (CAD) factor

Torque-in-base was an important issue with the first- and second-generation preadjusted brackets, because level slot line-up was not possible with brackets designed with torque-in-face. Technology was not available to set bracket slots in the correct position relative to the facial surfaces of the crowns without torque-in-base. Modern bracket systems, including the MBT'VI system, have been developed using computer-aided design and computer-aided machining - the CAD-CAM system. T his allows more flexibility of design, not only to place the slots in the correct position in the brackets, but also to enhance bracket strength and features such as depth of tie wing and labio-lingual profile. The computer is first able to locate the precise location for the bracket slot, relative to in-out distance and torque position for each tooth. Once this position is established, it can then build up the 'in-fill' areas to optimize all requirements of the brackets (Figs 2.6-2.8).

The brackets may be finished with all torque-in-base (full size and clear) or with a combination of torque-in-base and torque-in-face (mid-size) with absolutely no difference in slot position. Since the advent of CAD-CAM bracket design, it is not necessary to discuss this historical issue any longer!

Mbt Brackets Torque Face

Fig 2.6 Brackets with torque in base were designed so that the LA point, the base point, and the slot point were on the same horizontal plane. To accomplish this an acute (<90°) angle was required at the occlusal aspect of the bracket base, and an obtuse (>90°) angle at the gingival aspect of the bracket base.

Fig 2.6 Brackets with torque in base were designed so that the LA point, the base point, and the slot point were on the same horizontal plane. To accomplish this an acute (<90°) angle was required at the occlusal aspect of the bracket base, and an obtuse (>90°) angle at the gingival aspect of the bracket base.

Fig 2.7 The CAD system analyzes the ideal slot location and then designs the in-fill of the bracket as necessary.

Fig 2.8 The outcome of the CAD process is that the resulting bracket can have torque in base, torque in face, or a combination of the two.

Pre Adjusted Appliance

Fig. 2.10 A premolar bracket which is 0.5mm thicker than normal is useful for small upper second premolars.

IN-OUT SPECIFICATION Expression of in-out

The in-out feature of preadjusted brackets is 100% fully expressed, because the archwire lies snugly in the slot. The labio-lingual movement is rapid, and normally occurs in one visit. The original SWA in-out specification was therefore used as a basis when designing the MBTIM system.

Fig. 2.9 This case has small upper second premolars.

Upper second premolars

Andrews' 120 research normals all had teeth with full-size crowns in the labio-lingual dimension, but in clinical practice upper second premolars have small crowns in approximately 20% of cases. An alternative bracket, which is 0.5mm thicker than normal, is useful for such teeth (Figs 2.9-2.11). This feature is helpful in obtaining good alignment of marginal ridges in cases with small upper second premolars and is discussed on page 52. For cases with upper first and second premolars of the same size, the upper first premolar bracket is used for both teeth. Only a small inventory of upper second premolar brackets is required, and this should be monitored by one staff member.

Fig. 2.10 A premolar bracket which is 0.5mm thicker than normal is useful for small upper second premolars.

Fig. 2.9 This case has small upper second premolars.

Pre Adjusted Appliance
Normal bracket

0.5 mm thicker bracket

Fig. 2.11 Approximately 20% of cases have upper second premolars with small clinical crowns, and a bracket which is 0.5mm thicker is helpful in obtaining good alignment of marginal ridges without wire bending for these cases.

TIP SPECIFICATION

Pre Adjusted Appliance
2° 2D 2° 2° 3" 0C 0°
Fig. 2.12 Recommended tip.

Expression of tip

The tip feature of preadjusted brackets is almost fully expressed. A .019/.025 wire in an upper canine bracket with 8° of built-in tip will express most of that tip. More than 7° of the 8° will be fully expressed (Fig. 2.13). With light continuous force mechanics, tip can be well controlled, and tip specifications are fully and rapidly expressed in clinical use. The research figures for tip were closely adhered to when the MBT™ bracket system was designed, although small changes were made to the tip specification for molar and upper premolar attachments.

For all molars, a 0° tip bracket is recommended. If placed parallel to the buccal cusps of the molars, a 0° lip bracket will deliver 5° of tip for the uppers and 2° of tip for the lowers (Fig. 2.14). This issue has been discussed at length elsewhere, and the reader is referred to other texts for more detailed information.4

For the upper premolars, the authors prefer brackets with 0° of tip, compared with 2° in the original SWA. This places the crowns of these teeth in a slightly more upright position, more in the direction of Class I. It also reduces anchorage needs in some cases. The 2° may seem insignificant, but the total of 8° from the four upper premolars does become significant in anchorage terms. For the lower premolars, the 2° of mesial crown tip in the original SWA brackets works well, keeping the crowns inclined forwards in a Class I direction, and continues to be used and recommended.

Pre Adjusted AppliancePre Adjusted Appliance

Fig. 2.14 Upper and lower molar attachments have 0° tip. When placed parallel to the buccal cusps of the molars, this delivers 5° of tip in the uppers and 2° of tip in the lowers.

019/.025

Fig. 2.14 Upper and lower molar attachments have 0° tip. When placed parallel to the buccal cusps of the molars, this delivers 5° of tip in the uppers and 2° of tip in the lowers.

Fig. 2.13 The tip feature of preadjusted brackets is almost fully expressed, and there is less than 1° of 'slop' when a .019 / .025 rectangular wire is placed.

019/.025

TORQUE SPECIFICATION

Lateral incisors

Central incisors

Premolars Canines

Preadjusted Appliance

Molars

Molars

Premolars Canines

Lateral incisors

Central incisors

Fig. 2.15 Recommended torque specifications

Expression of torque

As discussed above, in-out and tip features are efficiently expressed by the preadjusted appliance system. In contrast, torque is not efficiently expressed, owing to two mechanical reasons:

• The area of torque application is small, and depends on the twist effect of a relatively small wire, compared with the bulk of the tooth (Fig. 2.16).

• In order to slide teeth, it is normal practice to use

.019/.025 steel wires in a .022 slot, because a full-thickness wire prevents sliding. These wires have 'slop' of about 10°, depending on the tolerances in bracket and wire manufacturing, and the amount of wire edge 'rounding' or Tadiusing' (Fig. 2.17).

Preadjusted Appliance

Fig. 2.17 A rectangular .019/.025 steel wire in .022 slot will have approximately 10° of 'slop'. The exact amount depends on the precision of manufacture of the wire and bracket slot and the amount of wire edge 'rounding' or 'radiusing'.

Fig. 2.16 Torque is not efficiently expressed by the preadjusted appliance system, partly due to the small area of torque application.

Fig. 2.17 A rectangular .019/.025 steel wire in .022 slot will have approximately 10° of 'slop'. The exact amount depends on the precision of manufacture of the wire and bracket slot and the amount of wire edge 'rounding' or 'radiusing'.

As a result of the relative inefficiency of preadjusted brackets in delivering torque, it was necessary to build extra torque into the incisor, molar, and lower premolar brackets, in order to meet clinical goals with a minimum of wire bending. Arch form factors, together with canine prominence and other issues, made it necessary to have brackets with three options for canine torque, as discussed on pages 44 to 48.

Z ui

Incisor torque

It is helpful clinically to have torque control (Pigs 2.18-2.21) which moves upper incisor roots palatally and lower incisor roots labially. This treatment requirement is necessary for many types of malocclusion:

• Class II cases, where Class II elastics can cause torque to be 'lost' on the upper incisors, and where lower incisors tend to procline during leveling and in response to Class II elastics.

• Class I cases, where correct incisor torque helps to achieve good anterior tooth fit.

Fig. 2.18 Upper central incisor bracket.

• Class III cases, where correct torque can help to compensate for mild Class III dental bases.

Fig. 2.19 Upper lateral incisor bracket.

Fig. 2.20 Lower incisor bracket.

Because of these frequent clinical requirements, there is generally a need for greater palatal root torque of the upper incisors and for more labial root torque of the lower incisors. For these reasons, the authors recommend +17° of torque for the upper central incisors, +10° of torque for the upper lateral incisors, and -6° of torque for the lower incisors (Fig. 2.21).

Lateral incisors

Lateral incisors

Incisor Torque

Central incisors

Original SWA

Central incisors

Lateral incisors

Lateral incisors

Normal Incisor Torque

Central incisors

Recommended

Central incisors

Original SWA

Recommended

Fig. 2.21 The authors recommend +17° of torque for the upper central incisor, +10° of torque for the upper lateral incisors, and of torque for the lower incisors to assist in movement of upper incisor roots palatally and lower incisor roots labially.

Canine torque

Andrews' 120 non-orthodontic normals were non-extraction adults. However, a typical orthodontic caseload is a different sample. The finding of -7° torque for the upper canines has proved to be satisfactory for most cases, but the original SWA value of -11 ° torque for the lower canines has not been satisfactory, as it tends to leave the lower canine roots in a

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Fig. 2.22 The upper canine bracket has -7° torque. When inverted it has +7° torque.

Fig. 2.22 The upper canine bracket has -7° torque. When inverted it has +7° torque.

Fig. 2.24 The lower canine bracket has -6° torque. When inverted it has +6° torque.

prominent position in most cases. Versatility is needed for canine torque values. A range of-7°, 0° and +7° torque is therefore available for the upper canines (Figs 2.22 & 2.23) and -6°, 0°, and +6° for lower canines (Figs 2.24 & 2.25), described on pages 44 and 45.

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Fig. 2.23 The upper canine bracket with hook has 0° torque.

Fig. 2.23 The upper canine bracket with hook has 0° torque.

Fig. 2.25 The lower canine bracket with hook has 0° torque.
Torque Molaren

Fig. 2.24 The lower canine bracket has -6° torque. When inverted it has +6° torque.

Upper premolar and molar torque

The upper premolar torque value of -7° has proven to he satisfactory in clinical use, and the authors continue to work with it.

For upper molars, on the other hand, the -9° of the original SWA has proven to be inadequate, and they prefer -14°, as this gives better control of the palatal cusps (Fig. 2.26). The -14° specification for the upper molars helps to reduce interferences during function, by preventing the palatal cusps from hanging down. It is important to have a sufficiently wide maxilla to allow this torque change. If not, conical plate interference prevents achievement of correct torque.

Fig. 2.27 Upper second molar tube.

Original SWA Recommended

Fig. 2.26 Upper molar attachments with -14° of torque give better control of the palatal cusps.

Fig. 2.28 Upper first molar tube.

Fig. 2.29 Upper first and second premolar bracket.

Original SWA Recommended

Fig. 2.26 Upper molar attachments with -14° of torque give better control of the palatal cusps.

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Lower premolar and molar torque

Many orthodontic cases have narrow maxillary arches, with the lower arches showing a compensating narrowing. These cases normally require buccal crown torque (uprighting) of the lower molars and premolars. Also, the original SWA first molar torque (-30°) and second molar torque (-35°)

Fig. 2.30 The authors have recommended substantial changes in torque features for the attachments in the lower buccal segments, compared with the original SWA. This reduces the 'rolling-in' of lower molars as well as assisting in the development of the mandibular arch.

specifications allowed 'rolling-in' of lower molars. Therefore the authors have made the important decision to change lower premolar torque by 5°, first molar torque by 10°, and second molar torque by 25° (Fig. 2.30).

Original SWA

Recommended

Original SWA

Recommended

Fig. 2.30 The authors have recommended substantial changes in torque features for the attachments in the lower buccal segments, compared with the original SWA. This reduces the 'rolling-in' of lower molars as well as assisting in the development of the mandibular arch.

Fig. 2.31 Lower first premolar bracket.

Fig. 2.32 Lower second premolar bracket.

Fig. 2.33 Lower first molar convertible buccal tube.

Fig. 2.34 Lower second molar tube.

Fig. 2.33 Lower first molar convertible buccal tube.

Fig. 2.34 Lower second molar tube.

THE VERSATILITY OF THE BRACKET SYSTEM

The first and second generation (p. 6) of brackets and buccal tubes had a single option for each specific tooth, with a recommendation for proper tip, torque and in-out compensation. There was little room for versatility. The MBT™ Versatile-f bracket system has overall design improvements compared with previous appliances. These include changes in tip and torque, as well as design features which introduce a new characteristic for the preadjusted system - that of versatility.

As described below, the innovation incorporates seven different bracket and buccal tube possibilities, depending on the needs of the case. This creates a platform for the archwires and the bracket system to produce the necessary individualization and overcorrection for certain types of case. The benefit can apply to individual teeth or to groups of teeth, in some instances. This reduces the need for first-, second- and third-order bends later in treatment, and improves efficiency.

Aspects of versatility

Seven main areas of versatility are listed below, and they will be reviewed in turn:

1. Options for palatally displaced upper lateral incisors (-10°).

2. Three torque options for the upper canines (-7°, 0°, and +7°).

3. Three torque options for lower canines (-6°, 0°, and +6°).

4. Interchangeable lower incisor brackets - the same tip and torque.

5. Interchangeable upper premolar brackets - the same tip and torque.

6. Use of upper second molar tubes on first molars in non-11C. cases.

7. LIse of lower second molar tubes for the upper first and second molars of the opposite side, when finishing cases to a Class II molar relationship.

Palatally displaced upper lateral incisors

The orthodontist is often called upon to correct upper lateral incisors which are palatally displaced. Cases with upper anterior crowding on Class 1 or Class III dental bases are liable to have upper lateral incisors which are in crossbite, and it can be difficult to achieve stable root correction. There is a risk of moving the crown labially, while leaving the root palatally placed. In this situation, there will be a need for additional wire bending, and treatment time will be extended.

A convenient way to manage these cases involves the following procedures:

• During the alignment stage, it is necessary to create enough space for the palatally displaced tooth. This is achieved using coil spring. The brackets on the adjacent teeth are tied with wire ligatures, to prevent rotations (Figs 2.35 & 2.36).

Palatally Displaced Teeth CorrectionHospital Relocation Form

Fig. 2.35 It is necessary to create sufficient space for palatally displaced incisors before attempting to move them labially. Bendbacks are placed 2 mm distal to molar tubes, to allow an increase in arch length.

Fig. 2.35 It is necessary to create sufficient space for palatally displaced incisors before attempting to move them labially. Bendbacks are placed 2 mm distal to molar tubes, to allow an increase in arch length.

Lateral Incisor Bracket Uppr Arch
Fig. 2.36 After creation of space, a .015 multistrand wire or a .016 HANT wire may be used to gently move the lateral incisors labially.

• The palatally displaced lateral incisor is bracketed with the normal bracket, but it is rotated 180° (Figs 2.37 & 2.38), which changes the torque from +10° to-10°. This assists in labial root torque at the rectangular wire stage. The tip stays the same at 8°. The left side bracket is placed on the left incisor and the right side bracket is placed on the right incisor. This is mentioned because it is a frequently asked question! It is not correct to place the left incisor bracket on the right incisor or vice versa.

Lateral incisor

Lateral incisor

Maxillary Incisor Torque

Rotated 180c

Fig. 2.37 Conventional placement of an upper lateral incisor F'9- 2.38 Rotation of the lateral incisor bracket by 180°

bracket gives +10° of torque. changes the torque from +10° to -10°.

Rotated 180c

Fig. 2.37 Conventional placement of an upper lateral incisor F'9- 2.38 Rotation of the lateral incisor bracket by 180°

bracket gives +10° of torque. changes the torque from +10° to -10°.

Lateral incisor

Lateral incisor

Central incisor
Rotated Lateral Incisor

In the following treatment sequence, the use of coil spring is shown, as a method of re-creating space to allow alignment of a palatally displaced upper lateral incisor. The coil spring was re-activated by using a split round tube (517-620 3M Unitek).

Fig. 2.39A A decision was made to extract upper first premolars and lower second premolars in this crowded Class I case with a palatally displaced upper right lateral incisor and an upper midline shift to the right. After initial leveling and aligning, a coil spring was placed to create space for the lateral incisor. The lower arch brackets were not placed at this stage, because a lower acrylic splint was likely to be needed later in the treatment.

Fig. 2.39B The case 1 month after Figure 2.39A. Space-opening procedures of this type should be carried out on .018 round steel wires or heavier wires. A section of closed coil spring is being used with the center part stretched to activate. By using closed coil spring in this way, there is normally not a problem with sharp ends, as can happen with open coil spring. Modules have been removed ready for adjustment and reactivation.

Placing Open Coil Spring Orthodontics

Fig. 2.39D Modules have been placed, and the patient will be seen again in 4 weeks. The coil spring will re-create space for the lateral incisor and help to restore the midlines.

Fig. 2.39C Here a split round tube has been placed onto the archwire to reactivate the coil spring. It is therefore not necessary to remove the archwire to reactivate. Teeth adjacent to the coil spring always need to be tied with wire ligatures, to prevent unwanted rotations.

Fig. 2.39D Modules have been placed, and the patient will be seen again in 4 weeks. The coil spring will re-create space for the lateral incisor and help to restore the midlines.

In the following treatment sequence, the correction of a palatally displaced upper lateral incisor is shown.

Open Coil Spring Crowded Teeth

Fig. 2.40B Open coil spring is being used to create space for the lateral incisor (p. 40) before an attempt is made to move it labially. Teeth adjacent to the coil spring are tied with wire. The upper left lateral incisor bracket is rotated 180°.

Fig. 2.40A This non-extraction case presented with an upper left lateral incisor in crossbite.

Fig. 2.40B Open coil spring is being used to create space for the lateral incisor (p. 40) before an attempt is made to move it labially. Teeth adjacent to the coil spring are tied with wire. The upper left lateral incisor bracket is rotated 180°.

Fig. 2.40C Rectangular steel .019/.025 working wires are in Fig. 2.40D The case after appliance removal, place. No additional wire bending was required in this case.

Three torque options for the upper canines (-7°, 0°, +7°)

Effective torque control of the upper canines is necessary, because they are key elements in a mutually protected occlusion. The goal is to deliver ideal tip and torque to the canines, so that they can fulfil their role in lateral excursions, and have a small amount of lateral freedom in maximum inter-cuspation.

The inefficiency of the preadjusted appliance in delivering torque is evident when working with canines, because they are the teeth with the longest roots in the human dentition. There will be less wire bending required if a correct selection is made from the three torque options which are available.

The MBT™ philosophy uses two types of upper cuspid bracket (Fig. 2.41) to provide three possible torque options (-7°, 0°, +7°).

0' torque

0' torque

Fig. 2.41 The MBTIM philosophy has three torque options for the upper arch.

Three torque options for the lower canines (-6°, 0°, +6°)

The original SWA value of -11 ° torque'1 was not satisfactory, as it tended to leave the lower canine roots too prominent in some cases. The authors prefer -6° lower canine torque, but for some cases they may use 0° or even +6°. They favor reduced lower canine torque, compared with the research findings, because lower canine roots sometimes show gingival recession, and benefit from being moved into alveolar bone. Also, in some deep bite cases, it is necessary to torque the canine crown labially and at the same time maintain the canine root in alveolar bone. The -6° figure coordinates well with the 5° torque changes made to the specification in the lower premolar region. The MBT™ philosophy uses two types of lower cuspid brackets (Fig. 2.42) to provide three torque options (-6°, 0°, +6°).

too i

0 torque

+6^ torque

0 torque

+6^ torque

Fig. 2.42 The MBT™ philosophy has three canine torque possibilities for the lower arch.

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When should the three canine options be used?

There are six main factors which govern selection of canine brackets:

1. Arch form

2. Canine prominence

3. The extraction decision (tip control)

4. Overbite

5. Rapid palatal expansion

6. Agenesis of upper lateral incisors, where space is to be closed.

Arch form

[f the patient has well-developed arches, and if substantial tooth movements are not required, then -7° upper and -6° lower canine brackets are normally chosen. A more ovoid or tapered arch form may suggest the use of 0° torque brackets for upper and lower canines. If the patient clearly has a narrow tapered arch form (Case AL, p. 86), then +7° upper and +6° lower brackets will be beneficial in many cases (Figs 2.43 & 2.44).

Tapered Lower Arch

Lower

-6;'torque

,' . Square or ovoid arch form

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0" torque

Ovoid or tapered arch form

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Responses

  • hanna burns
    How do you express torque in lateral incisor turn?
    4 years ago

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