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CHAPTER 6

David Surez Quintanilla, Cristina Barreiro Torres, Jos Mara Llamas Carrera, Mnica Suqua Altolaguirre

Straight Wire Low Friction Technique

DETAILED FEAURES OF THE TECHNIQUE AND APPLIANCE


The exercise of our profession is currently being shaped, and will continue to be shaped, by changes of three different kinds: conceptual, technological and socio-economic change. With respect to conceptual changes, so-called Evidence-Based Orthodontics (EBO) ensures that our diagnoses, treatment and clinical activities are based on proven scientific evidence rather than subjective opinions, individual experience and biased personal interpretations. EBO sets the clinical standard and represents the future of this profession. Although admittedly limited, recent advances in our knowledge of the biology of dental movement highlight the need for the forces employed in our treatments to be intermittent, light, constant and prolonged. Many of the best-known and most widespread orthodontic techniques were invented and developed at a time when nothing was known of the current advances in orthodontics (miniscrews and miniimplants, new elastomeric materials , osteodistraction devices, etc) and when the properties and behaviour of shape memory wires, the first NiTi wires, were far removed from the highly effective and superelastic alloys we have today. Unlike classical nickel-titanium wires, the new superwires are not subject to the usual laws of physics and deformation and load and/or force generated by the wire are independent. Furthermore, if some practitioners have kept abreast of developments concerning the new

wires and how to handle them, if the engine of current superelastic forces has changed, why should we continue to use a bracket design which is over seventy years old and which limits the effectiveness of the new materials?

Fig. 2. The application of excessive forces, especially when constant, produces the necrosis of the periodontium; increases the indirect or distantly resorption areas; diminishes the velocity of dental movement, lengthens treatment time, and can cause the deterioration of the cementum and the dentin. Intense and prolonged forces favour Orthodontic Radicular Resorption.

Fig. 1. Nowadays Evidence Based Orthodontic (EBO) shows us that the Orthodontic Tooth Movement (OTM) is the result of complex biomechanical, biophysical and biochemical mechanisms. Orthodontic brackets must transmit efficiently the forces generated by wires and elastic materials to the periodontium to enable the action of osteoclasts and fibroblasts, the main agents of orthodontic tooth movement. Notwithstanding the advances made in orthodontic tooth movement, certain fundamental questions still remain to be answered like how to apply the forces in order to make treatment quicker and more effective.

Fig. 3. One of the greatest advances in the field of orthodontics in the last ten years has been undoubtedly the super-elasticity. This property makes possible the application of light and constant forces over a long period of time, even with rectangular wires. The super-elasticity has improved the Orthodontic Tooth movement by favouring the growth of the alveolar bone and reducing the need for extractions. The new superelastic and thermoelastic wires have simplified the biomechanics of our treatment processes, making them simpler, quicker and less discomfortables for patients. Unlike the traditional NiTinol (yellow) arch wires, the new superelastic wires (green) exert a constant force despite the degree of deformation caused by inserting them in the brackets .The superelastic qualities permit us to select the force exerted on the teeth, independently of their cross-section and calibre.

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SWLF is not just a technique involving a bracket; we have attempted to incorporate all the recent technological advances in orthodontics into an extremely simple therapeutic protocol and system of biomechanics. The technological changes affecting modern orthodontics, which have lead to the creation of the Straight Wire Low Friction (SWLF) technique, are thermoelastic wires, the latest generation of titanium-molybdenum wires, low-friction brackets and orthodontic microscrews. The SWLF technique enjoys all the advantages of the traditional straight wire approach but eliminates one of its main failings: static and dynamic friction. Although friction ensures occlusal stability and three-dimensional control over the root in the last stages of treatment, it is equally true that it is also the principal obstacle to dental alignment and levelling, thereby reducing the effectiveness of super-elastic wires, decreasing the potential for dental movement with these wires and, in short, complicating and prolonging our treatments. Thanks to the cooperation between the Orthodontic Departament and Mathematic Departament of the University of Santiago de Compostela (Spain) and the Rocky Mountain Orthodontic laboratories in Denver (USA) we are developing the brackets, wires and elements of the SWLF technique:

Fig. 6. The New Aesthetic Synergy shares the design characteristics of the metal Synergy (3 pairs of tie-wings of which the central pair is raised to avoid friction) with the advantage of a better aesthetic appearance. Its slot is made in gold and has opening endings with the double purpose of diminishing the friction and allowing quick insertion of the superelastic rectangular arch wires. The New Ceramic Synergy is ideal for use with aesthetic wires.

Synergy Brackets: Synergy Classic Synergy Fx: A new design of the Synergy Classic. Ceramic Synergy with slot made in gold to reduce the friction. New SWLF Superwires kit in a well designed box with a simply and clear chart for their selection: Thermoelastic wires for the alignment phase: Thermal NiTi (.013, .015, .017, etc) Beta III Titanium for the finishing phase and pliers to make intraoral bends at the end of the treatment. New Low Friction Ligatures New Elastomeric Modules Conventional Crimpable Hooks and a new design of pliers to fit them in the mouth. Long Crimpable Hooks to combine with Miniscrews. Miniscrews and different accessories to use them.

Fig. 4. The friction generated by traditional brackets depends to a great extent on the positioning, calibre and composition of the wire, the ligatures (LG), as observed in the two macrophotographs produced by scanning electron microscope; the design (size and surface composition) of the slot and the dynamic friction angle (AFD) formed by the wires major axis and the slot, that greatly affects dynamic friction and initial alignment.

BIOMECHANIC FEATURES
The Synergy Bracket has all the advantages and ease of use of a traditional straight wire twin bracket (the orthodontist who has been using other brackets does not need to familiarise himself with a different bracket when changing to the Synergy technique), but it does add certain new ingenious design features which provide three fundamental clinical improvements by enabling:

Maximum sliding in the initial stages of treatment with superelastic wires. The Synergy system has 3 pairs of tie-wings rather
than 2. The sides of the central tie-wings are raised in such a manner that when the ligature is applied solely in the cen-

Fig. 5. The Synergy bracket: is one of the most popular low friction brackets with the longest track record. Its innovative design provides individual and selective control over friction, anchorage and tooth movement, as well as a drastic reduction in the number of wires employed compared to traditional Straight Wire brackets. The Synergy bracket, based on intelligent design concepts, is simple and comfortable to use. It does not produce more emergencies due to debonding or breakage than a traditional bracket and is similar in price to any other metal bracket. It has three wings, of which the central wing (indicated by an arrow) is raised to prevent contact between the wire and the ligature. The arch slot is rounded at the ends making the insertion of super elastic rectangular arch wires easier from the earliest stages of treatment (AFD = dynamic friction angle).

Fig. 7. The singular design of the Synergy bracket allows us to insert super elastic rectangular arch wires at an early stage without fear of producing damaging force pairs due to the rounded design of the slot ends which softens the dynamic friction angle (DFA).
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Fig. 8. Studies conducted in collaboration with the Department of Applied Mathematics at the Universidad de Santiago and the Galician Super Computation Centre demonstrate that the distribution of stress in the Synergy bracket is superior than in a traditional SW bracket when we insert a .019 x 25 super elastic rectangular arch wire. The arrows indicate the areas of maximum friction and stress (at the slot endings in the traditional bracket and inside the slot in the Synergy bracket). tre, the contact between the wire and the ligature is minimal or non-existent, thus reducing friction almost to zero and optimising the effect of the superelastic wires. Numerous studies have demonstrated that alignment with superelastic arch wires in a case with pronounced irregularity is much swifter and effective with low-friction brackets such as Synergy than traditional single or twin brackets.

Fig. 9. The major problem with classic brackets of SW is the friction generated by elastic and metallic ligatures. This friction can reduce by more than 60% the effectivity of the superelastic wires during the alignment phase. The classical twin brackets present the problem of static and kinetic friction. The Synergy bracket avoids these problems thanks to the unique design of its wings and its slot.

Early use of rectangular archwires. One of the problems caused


by use of traditional brackets, which have slots ending in 90 angles, is the biomechanical difficulty of inserting rectangular wires at the beginning of treatments and the need to employ laceback or tieback ligatures to achieve distal movement of the canines (in many techniques the use of laceback ligatures depends on the design limitations of the classical SW brackets rather than the limitations of the biology of orthodontic dental movement). The Synergy brackets provide an ingenious response to these difficulties, with rounded arch slot openings to allow for quick insertion of the superelastic rectangular arch wires and making tieback ligatures obsolete in the process. Slots which are rounded both on the floor and at the ends avoid the adverse effects of the early insertion of rectangular arch wires, i.e., the inadequate couples and the excessive initial movement of the roots allowing for earlier utilization of larger steel wires for the closing of spaces and torque. Synergy presents simple, but very ingenious new design features that improve the biomechanical effectiveness of the wires, and shorten and simplify treatment, given that less wires, less chair time and less visits are needed. There are also other self-ligating low friction brackets with similar characteristics to Synergy, but for me, they are more difficult to bond and handle. They are too bulky, pliers and special keys are necessary for their handling, on occasions

Fig. 10. The key therapeutic aspects of SWLF are: the different variants of the Synergy bracket, the use of the newest alloys (Thermal NiTi, Beta III Titanium, etc) , the practical and simply standardization on the archwire selection and the use of multipurpose systems (crimpable hooks, special pliers, elastic modules, low friction ligatures, etc).

Fig. 11. The great advantage of the Thermalloy is the capability to generate light, constant and prolonged forces, independents of wire deflection and deformation. The phase change of the Thermalloy is produced near to 33C.

Fig. 12. Selective tooth by tooth control can be achieved by the way of ligation. When ligating in the centre the friction generated is minimum and the sliding/dental movement is maximum. If we ligate one canine bracket in the centre and the counterlateral in a figure of 8, we will increase the friction of the last one and its dental movement resistance.

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the cap can break, the colourful ligatures which children like so much cannot be put into place without losing part of their biomechanical effectiveness and, importantly for our pockets, they cost four times more and the patient does not like to pay more for metallic brackets. ature (materials and shape) it would be possible to control friction, or its opposite, sliding, tooth by tooth. Unlike low-friction self-ligating brackets, which are excellent during alignment but of limited use for dental control in the torque and finishing stages (in my experience it is not easy to finishing the cases with self-ligating brackets) , the Synergy bracket allowed us to obtain friction (with elastic or metallic ligatures placed conventionally or in a figure of eight) when the treatment required excellent tooth control. Remember that the friction, during orthodontic treatment, is not bad itself. In many cases we need friction to move the teeth!

Individual "tooth by tooth" control of tooth movement and anchorage. The main advantage of the Synergy bracket over other
low-friction brackets, whether standard or self-ligating, is the ability to control dental movement and anchorage tooth by tooth only changing the ligature. We can basically ligate in three ways: In the centre "C". To achieve maximum sliding and maximum tooth movement. We ligate in this way when we require maximum displacement: in initial phases of alignment with round or rectangular superelastic wires, for distalizing canines or lateral sectors etc. Standard O. We ligate the corner wings just like a conventional twin bracket, thus achieving maximum control of rotations and a medium amount of sliding. The friction created by contact between the ligature and wire will condition the degree of tooth movement. We use the new low friction ligatures when we need at the same time low friction and control of the rotations. In a figure of 8. In this particular case, we produce close wire-ligature-slot contact, thus obtaining total expression of the wire on the bracket and maximum control of the root. Thus, we ligate the teeth where we want to have perfect control over the three planes, where we need to maintain or recuperate torque and/or we want to obtain tooth anchorage through fiction.

Prescription
With the benefit of hindsight since the initial Andrews prescription, we are aware that the only novelty in many of the earlier new techniques was a small, clinically insignificant, variation in angulation and/or torque. The SWLF technique would not have merited any attention if it had solely offered yet one more prescription. Although we believe that preadjusted brackets help to simplify treatment, we do not feel that small variations in the tipping and torque figures, are determining factors when choosing one technique over another. The scientific literature we have consulted in respect of the differences between prescriptions confirms our views and reveals that many of these prescriptions are little more than marketing exercises. Small modifications of a few degrees, particularly when the largest calibre wires used by the majority of practitioners are those which still allow for a considerable degree of free space on the inside of the slot (.017 x 25 in a .018 slot and .019 x 25 in a .022 slot), have no noticeable clinical effect at the end of treatment. The evident commercial side to prescriptions (their use to differentiate the brackets of one author from those of another) will be clear to the practitioner who analyses the torquing play between a thick 0019 x 0025" wire in a 0022" slot. The freedom of movement (the degree to which the wire is able to turn on itself within the bracket) is over 30C!. Are a few

The concept of selective friction control tooth by tooth (SFC)


Low-friction brackets are now all the rage and all the orthodontics manufacturers are racing to improve arch/bracket sliding. Many in the profession have opted for conventional low-friction brackets, self-ligating brackets or mixed low-friction brackets. RMO opted for the selective friction control tooth by tooth alternative with its Synergy bracket many years ago. When I started to use the Synergy bracket over eight years ago, I soon realised that it was not only a lowfriction bracket, but that it also had the capabilities of a conventional bracket and that simply by modifying the lig-

Fig. 13. The Friction Selection Control concept is very important. We can control the friction, the sliding and the orthodontic tooth movement only by changing the ligature. During the alignment phase with superelastic wires we need less friction because the wire must be free; quite the opposite happens during the finishing phase when we need more friction, good torque and tooth control. In this case we ligate the last arch wires (Beta III Titanium) in a figure of 8.

Fig. 14. SWLF Prescription.

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degrees variation in an incisor so important? Isnt a significant part of the battle of the prescriptions a question of marketing rather than science? Is there such a great difference in the outcomes between one prescription and another? Which has most bearing on the outcome; a few degrees of torque or dental anatomy and the variations between each individual patient and each malocclusion? We have used these simple and clear ideas as the basis for a prescription which aims to approximate itself to the average values in the most popular prescriptions while leaving the canines and incisors with standard values. We believe it is important to overcorrect the torque in the upper central incisors (17) due to their tendency to lose torque during retraction with thick rectangular arch wires. In relation with the Roth prescription we have reduced the overcorrection of the torque and rotation of molars and the inclination of the upper canine by up to 8 where the use of conventional brackets means that distal shift of the canine is less likely than with SWLF. The same philosophy has led us to opt for the standard prescription in the lower incisors, where negative radicular torque of only a few degrees can create undesirable contact between the fine roots of the incisors with the thick cortical vestibular and give rise in certain patients with little inserted gingiva or an unfavourable periodontal biotype to radicular reabsorption and/or gingival recession. Modifying lower incisor torque is very often more the wish of the orthodontist than a clinical reality, which frequently comes up against the limitations imposed by the cortical bone. One of the most fascinating aspects of orthodontics is that no two patients, or their mouths, are ever the same. Practitioners are aware that the values given by the distinct prescriptions are no more than approximations to the ideal and individual prescription for each of our patients, with the result that when we reach the stage of finishing and detailing the occlusion, we have to individualise our prescription with some 1st, 2nd and 3rd order bends in the arch wire. For this purpose we recommend the use of Beta Titanium III as final arch wires. Beta Titanium III allows us to create bends inside the mouth, without removing the arch wire, in order to make our prescription more precise and tailored to the patient. effect of dental movement on the physiological force levels and prevents the creation of intense forces in the case of particularly uneven arches. One practical effect is the ability to create severe deflections in the arch wire, as when aligning canines in high vestibular position, without generating the excessive, even iatrogenic forces formerly produced by traditional NiTi wire, which obeyed Hookes Law and generated huge forces when deformed, creating a risk of periodontal necrosis, ankylosis and/or radicular resorption of the tooth and loss of anchorage and stability in neighbouring teeth. As its name indicates, the edgewise technique, from which our own technique is derived, draws its principal therapeutic effect from rectangular steel wires. As a result, our aim is to align and level the arches as soon as possible in order to arrive at these arch wires equally swiftly, while employing the minimum number of wires to do so. As the new rectangular superwires come in varying pre-set force levels, we can clinically reduce the number of prior round arch wires (we do not see why it should be necessary to use square arch wires). As a result, in most of our treatments we reach

Biomechanical advantages of the new SWLF wires


The team of engineers at RMO-Denver has developed new high-tech arch wires for the SWLF technique, particularly for the alignment stages (Thermoelastic wires) and the finishing and detailing stage (Beta-III Titanium Wires). We made use of the traditional stainless steel RMO wires for the finishing and detailing stage and NiTi arch wires with Spees curve for levelling. We have also added new .013, .015 and .017" calibres which are better adapted to the requirements of alignment, both for .018 and .022" slots. The new Thermal NiTi SWLF wire is characterised by a high degree of elasticity and the generation of very light forces, independently of the amount of arch wire deformation. The patients intraoral temperature aids the phase change (from martensite to austenite and vice versa). The new thermal NiTi SWLF wires produce light, constant and prolonged forces, they optimise dental movement during the initial alignment process and allow the patients best arch shape express itself through the stimulus it gives to the formation of alveolar bone. In the Thermal NiTi SWLF the force is predetermined by the manufacturer and, strictly speaking, remains the same whatever the degree of deformation applied to the arch wire when inserting it into the brackets in order to align the teeth. The fact that the forces are predetermined and constant, particularly when they are located in the light to medium band (between 50 and 100 grams), heightens the

Fig. 15. Selection of Arch Wires for the 0.022 Slot Synergy (also available in 0.018 slot).

Fig. 16. Method of ligation in each phase of the treatment.

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Fig. 17. Depending on the biomechanical needs of each tooth, the arch wire is ligated to each bracket in the centre C in order to maximize the distal sliding of the canines; and the upper premolars, in a figure of 8 in order to allow the arch wire maximum expression of torque over the incisor and to maintain or recover torque, or in a conventional 0 shape for rotation control.

Fig. 18. The sequence reflects the great advantages of combining super elastic wires and Synergy low-friction brackets. A: Initial phase with Class II molar and premolar and a clear lack of space for the canine. B: Initial Thermaloy 017 arch wires with the upper canines and premolars ligated in the centre for increase sliding and swifter alignment. D: Treated patient with correct occlusion. Appointments: 8. Time: 14 months.

Fig. 19. One of the auxiliary elements in our SWLF technique, which helps to reduce the number of extractions, is the mechanical stripping with diamond files of differing grain sizes. Immediately following alignment we start regular appointments for doctors and hygienists for sequenced mechanical stripping, which we have called Orthostripping and which allows us obtain between 4 and 6 mm per arch, thus avoiding the need for extractions in many adults. The procedure is does not cause much discomfort and is practically innocuous, nor does it increase susceptibility to decalcification or caries, providied the patient is suitably monitored. As indicated by the arrows in the intra-oral photograph, we also use stripping between the posterior teeth.

Fig. 20. Great overcrowding in clinical cases treated with Synergy bracket, the SWLF archwire sequence and Orthostripping.

Fig. 21. Class II-2 in an adult treated with lower Orthostripping.

Fig. 22. The crimpable hooks are very versatile and multi-purpose. We can use them to close spaces, distalice the molars and even to lose anchorage.

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Fig. 24. Combination of miniscrews with the Wilson molar distalization system without cooperation.

Fig. 23. One of the key elements of our SWLF Technique is the combination of our bracket and wire biomechanics and the extensive use of miniscrews for anchorage control, the distalization and 3D molar control, and the correction of the anterior openbite.

extremely important role in this technique, and some of these items, as with the new crimpable hooks and pliers system, have been specifically designed by RMO-Morita in Japan. When the Synergy bracket is ligated in the centre, and also in the conventional position, it is advisable to use special low-friction ligatures in order to control rotations. RMO have developed in Japan some excellent low-friction ligatures coated with a polymeric film which increases their ability, compared to conventional ligatures, to slide when they come into contact with saliva. We employ RMOs Energy Chain for closing adjacent spaces and the new elastic SWLF modules for remote traction, e.g. from the canines or posts in .019 x 25 closing loop arches. We feel that modules are more hygienic as well as effective and provide us with a greater degree of control over the force applied. At the current time, we are designing a new traction system for space closure achieved either conventionally or in combination with micro-screws, based on elastic modules, superelastic springs and new crimpable hooks.

Fig. 25. In SWLF the use of miniscrews for molar control simplifies the treatment of cases of openbite due to vertical posterior excess.

METHODOLOGY: CHOICE OF WIRES


There is a Chinese proverb which states; give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime. When teaching staff on training courses introduce students to a specific technique, they are often prone to hand out fish rather than teach students to fish. This leads to teachers choosing wires as if from a recipe, which is highly unsatisfactory given that there is no spur to change to new wires and clinical evolution is blocked. The criteria we use to choose wires are simple and ready to embrace the developments which orthodontic manufacturers will undoubtedly produce in the future. One of the keys to achieving a high degree of clinical effectiveness in orthodontics, i.e. quick treatments with only a few short visits, is the appropriate selection and use of the arch wires. We should use a small number of high quality wires which are able to generate light, constant forces over long periods. The new alloys allow us to reduce the number of wires used in the different stages of treatment. We adapt the new SWLF wires to the biomechanical requirements of each phase:

.019 x 25" stainless steal arch wires in a .022" slot after the use of just one or two prior arch wires. The new wires have a longer average activation period than traditional NiTi arch wires. We are therefore obliged to amend our practice of seeing patients once a month in order to change arch wires and ligatures, and to allow the wires to act and express the prescription for 6 to 8 weeks. The properties of thermo elastic wires alter in response to the change in temperature from the austenite to martensite phase. Given that intraoral temperature is a constant, at 36.5, the metallurgical industry is conducting research into new wires capable of precise adjustment of their phase change to this constant working temperature. Differential heat treatment also enables one single wire of uniform calibre to contain distinct levels of elasticity/rigidity in the anterior-incisor, premolar and posterior molar regions, which brings us yet closer to EH Angles dream of one single wire for the whole treatment process. We use in the finishing phase the SWLF Beta-III Titanium. It is a titanium-molybdenum wire with the best elastic properties among nickel-titanium wires and the conformation ability of steel. This is the ideal wire for final detailing of the occlusion and is highly effective when combined with short and strong elastics and the special SWLF step pliers (for 05 and 10 mm) for intraoral correction of small defects in first, second and third order compensations when we are concluding the treatment.

Low friction ligatures


Ligatures, elastic chains and elastic modules play an

Alignment Phase. At the Alignment Stage we require super elastic wires with excellent shape memory which are highly elastic and capable, even in rectangular wires, of generating light, constant and prolonged forces. The wires must be optimal in order to produce, in the words of Professor Jos A Canut, the periodontal awakening which sets in motion the cellular reactions and histochemical mechanisms which will lead to orthodontic dental movement and the formation of alveolar bone. We must allow the new wires to slide smoothly and freely through the brackets and to express the best possible arch shape for each patient. For many years this initial stage of treatment was overlooked, but we
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Fig. 26. Class I with light crowding and low irregularity index treated with SWLF in 12 months and 8 appointments. Fig. 27. Class I with maxillary compression and crossbite of the 22, treated with SWLF in 16 months and 12 appointments. now consider it to be of key importance for the rest of the treatment. In cases where we are unsure whether to expand or extract, we await the end of this stage before making our final decision.

Levelling Phase. At the levelling stage we employ the RM Ricketts utility arch approach in mixed dentition or as an auxiliary element as part of intrusion in permanent dentition, and we use preformed curve of Spee nickel-titanium arch wires in the remaining patients where we need to level due to an excess of overbite or overbite effect. The biomechanics of these wires are controlled by the simple use of intermaxillary elastics: posterior when we require greater anterior intrusion, as in the case of overbite due to extrusion or excessive anterior dentoalveolar growth, and anterior when we require posterior intrusion, as with open bite cases. Space Closure Phase. We must combine sliding and canines
and premolars shifting en masse with friction and the retention of torque in the incisors. Our wire of choice is the rectangular stainless steel due to the ability to combine rigidity for achieving and retaining radicular torque with an excellent surface for sliding. The space closure stage has been one of the challenges to which traditional Straight Wire techniques have been unable to provide a satisfactory solution. The friction generated by

conventional twin brackets during sliding, with the resulting obstructed movement and loss of anchorage, led to the several variations on the original Andrews technique to opt for preformed arch wires and wire/bracket displacement, which has the effect of reducing the biomechanical effectiveness of the wires and other elastic elements. The results of these biomechanical difficulties are plain to see in the high rate of extractions which clinicians are obliged to carry out when using the Straight Wire technique with traditional brackets. Space closure in our technique is very much improved by use of the Synergy bracket in conjunction with the SWLF prescription, due to its multi-faceted nature when selectively choosing the degree of sliding required tooth by tooth. Given that one of our aims in developing the SWLF technique was maximum versatility and simplicity, we opted for the inmouth positioning of hooks for space closure. RMO has developed new hooks for this technique with the appropriate size and a rounded surface, as well as a new pair of pliers for placing them quickly and simply on the arch. This alternative has innumerable advantages; it makes it possible to convert a conventional rectangular arch wire into a selective closing loop arch, we can choose exactly where we intend to produce closure and if it is unilateral or bilateral, symmetrical or asymmetrical, it can be combined with other additional parts such as intermaxillary elastics , distalization springs, miniscrews and it avoids the need to keep large and varied stocks of preformed arch wires with crimpable hooks.

Fig. 28. Dental Class II and Skeletal Class I with lack of space for the upper canines, treated with SWLF and multipurpose crimpable hooks in 14 months and 12 appointments.
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Fig. 29. Typical sequence of SWLF wires (Thermal NiTi Stainless Steel Beta III Titanium) in the treatment of a 12.5 year old patient (17 months and 14 appointments).

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Fig. 30. Combination of SWLF archwires and mechanical orthostripping in the treatment without extractions of a 12 year old patient with a severe Class II and great crowding. You can see de result of the treatment 3 years after the end of the treatment. We use the typical sequence of SWLF arch wires (Thermal NiTi Truchrome Beta III Titanium).

The simplicity of space closure in the SWLF technique makes it possible to space out appointments for monitoring and activation purposes and to reduce chair-time. The Synergy bracket guarantees excellent sliding of the arch wire in lateral areas and the retention of torque during incisor retraction.

Finishing Phase. Our aim is to ensure that the occlusion settles, to maintain torque and to correct small final irregularities. This is a very important stage, for which our first-choice wire is Beta III Titanium, a new Titanium-Molybdenum wire specifically developed for the SWLF technique.

Fig. 31 to 34. Class I malocclusion with skeletal maxillary compression /collapse . We decided to combine the use of the RME with SWLF Technique. RME (Rapid Maxillary Expansion) and initial alignment with Thermal NiTi (31). For finishing purposes we employ Braided SS or Beta III Titanium and special pliers which enable us to make small steps inside the mouth and achieve final detailing with short and strong elastics. Performing occlusal and aesthetic detailing inside the mouth is very practical task due to a combination of three elements Beta III Titanium, short-strong elastics and the pliers to make 1.5 mm steps (32). End of the treatment (33). You can see the difference in the maxillary arch shape between the start and the end of the treatment. The main advantage of this wire is that it achieves a perfect balance between elasticity, resilience and an ability to conform. The new Beta III Titanium allows us to make

Fig. 35. In more than 80% of Class II growing patients we combine simultaneously light (thermoelastic SWLF wires) and intermittent forces (Functional Appliances and Head Gear).
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Fig. 36. Treatment of a 11 year old Class II-1 patient with Functional Appliances, SprinGear (a special Head Gear with a NiTi coilspring) crimpable hooks, elastic modules and Class II elastics ( 16 months and 12 appointments).

Fig. 37. Closing spaces is an extremely simple, practical and inexpensive process to convert a standard 19 x 25 steel arch wire into an excellent closure wire thanks to the placing of intra-oral hooks to enable intra, or intermaxillary elastic traction. We have been using handmade and/or preformed closure arches for many years, but we realised that posts offered significant advantages in terms of clinical effectiveness and cost. Fixing the posts on the 019 x 25 arch wires is so simple that it is achieved in situ in the mouth with special pliers. Treatment of a 14 year old Class II-1 patient with Functional Appliances, SprinGear, crimpable hooks, elastic modules and Class II elastics ( 18 months and 13 appointments).

Fig. 38. The technique achieves space closure through elastic modules on the posts or hooks on the 019 x 25 arch wire and ligatures in the centre of canines and premolars for maximum distalization. Class II elastics can be placed on the canines or the upper posts. Patient with a severe dental and skeletal Class II treated without extractions with SWLF and Functional Appliances, SpringGear, crimpable hooks, elastic modules and Class II elastics (16 months and 12 appointments). Fig. 39. Severe and complete Class II-1 in which we first use a combination of C Modeler by Dr. Cervera ( Spain) and a Bimler Myodynamic Appliance modified by ourselves (Ortoflex). Following this first stage we use rectangular levelling archwires, closing archwires with posts and Class II elastics, and 19 x 25 Braided SS. Appointments: 12. Time: 18 months.

sion, and there is no difficulty maintaining torque, we use braided steel, rectangular braided SS arch wires.

Arch wire selection criteria


The choice of arch wires must be practical and versatile, and cannot simply be a recipe which becomes obsolete upon the invention of new and better alloys. On the other hand, it is not an easy or realistic task to programme each and every one of the arch wires to be used in a specific treatment from the very beginning. In the SWLF technique, we have decided to select the preformed arch wires at each phase or stage of treatment independently, having regard to clearly established criteria which are nevertheless open to the diagnostic skill of individual practitioners. After completing each stage, and before commencing the next, we will assess the results achieved thus far and, of great importance, we will ask ourselves whether or not we could achieve more and improved results with the arch wires the

Fig. 40. Class II-1 treated with Functional Appliances (RF by Frankel) and SWLF (18 months and 14 appointments).

intraoral bends with SWLF pliers without the need to remove the arch wire from the brackets, which reduces chair-time and appointments at a time when the patient is eagerly awaiting the end of treatment. In those cases where there is no need for a great deal of detailing due to the results already achieved or the patients biological characteristics and/or their malocclu-

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patients already have inside their mouths. We should not be in a rush to change arch wires. We must be able to squeeze the most out of the new super elastic wires used by this technique. It should not be forgotten that in the SWLF technique the way in which the ligatures are attached (at the centre, conventionally, in a figure of eight, etc.) opens up new possibilities in comparison with other techniques. It is not always necessary to complete all the stages; sometimes the malocclusion might not require levelling (where the overbite and the Curve of Spee in the arches are normal) or space closure. It is not unusual with the SWLF technique to complete many treatments with two arch wires per arch.

Arch wires We require super elastic wires generating light,


constant and prolonged forces. We use the THERMAL NITI, a nickel-titanium thermoelastic wire with shape memory which undergoes a reversible process upon changing phase (austenite phase martensite phase) as a result of the patients intraoral temperature. THERMAL NITI is offered in a range of new calibres (.013, .015 and .017). The calibre is chosen in accordance with the slot (.018 or .022), the irregularity index and the SDD.

Clinical details
How to ligate. In general, all teeth are initially ligated in the centre to avoid friction and thereby guarantee maximum sliding. On those teeth furthest away from the arch we recommend using metallic ligatures. As the wire is thermoelastic we cool it locally with a cotton bud dipped in cold water or ice to ease insertion. Care should be taken to ensure that the wire remains unimpeded, i.e., that it can slide smoothly when we pull on it from behind the finishing tube. If appropriate, at a second appointment, with the same arch, now reactivated, we recommend ligating in the conventional manner to control rotations. When to ligate distally. In general, when we do not wish to see a marked increase in the arch length, we recommend ligating the wire distally (either by burning it at the ends or bending it with special pliers). In general, we ligate distally in upper and lower Class I cases with biprotrusion, only on the upper distal in Classes II/1 and solely on the lower distal in Class III. Allow the wire to express itself. THERMAL NITI is an excellent wire and needs time to take effect. Allow it to act over 6 to 8 weeks before assessing its effects. THERMAL NITI can be reactivated by removing it from the mouth and expanding it with the aim of extraorally facilitating its phase transformation.

Alignment
Aims

Initial periodontal awakening with light forces. Crown alignment and straightening Control of rotations Dentoalveolar expansion and development. Expression of the optimum Arch Form for this patient.

Selection criteria

Irregularity index. Sum of the distances between points of contact of adjacent teeth. When irregularity is low, we can commence treatment, thanks to the design of the Synergy brackets slot with its rounded ends, with the ligature in the centre and with the use of rectangular wires. It must be considered whether the irregularity is localised or generalized. Skeletal-dental discrepancy (SDD) or crowding.

Levelling
Aims

To correct vertical problems. To correct Spees curve in each arch. To correct increased or decreased overbite according to the facial biotype and the growth tendency.

Selection criteria Overbite and facial biotype In patients with


Fig. 41. Class II-1 with maxillary compression and severe crowding treated with premolar extractions and SWLF. increased overbite ( 2/3) we must evaluate the degree of dental-gingival exposure with posed smile, the facial biotype and the lower facial height. In general, we use NiTi Curve of Spee arch wires in order to intrude incisors and extrude molars. We use posterior elastics to increase posterior extru-

Fig. 42. Early mixed dentition class III patient treated in 2 phases. In the first one we use a Removable Appliance (Progenie Arch) to correct the anterior crossbite. In the second phase we used the archwire standard sequence of the SWLF Technique.
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Fig. 43. End of treatment. (First phase: 9 months. Second phase: 14 months)

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Fig. 44. The reversed curve of Spee arches and the crisp-shaped arches such as SWLF Curve Spee NITI are excellent for correcting Class II/2 incisor overbite in a quick and simple manner. In cases of serious overbite where there is a strong biomechanical requirement for intrusion of incisors, we can exploit the advantages of super elastic rectangular arch wires in conjunction with extra-oral cervical traction with high outer bow.

Fig. 45. Sometimes in Class II patients with severe overbite we use NiTi o Beta III Titanium arches with springs for incisor intrusion. Severe Class II with intense overbite greater than 3/3. A composite incisal plane is used on the lingual surface to release the lower arch and make it possible to place brackets on it. We then use curve of Spee arches, with posterior elastics and preformed 19 x 25 protrusion/retrusion arch wires. Appointments: 12. Time: 19 months.

Fig. 46. The combination of the Synergy bracket with superelastic and Curve Spee archwires, crimpable hooks with coilspring and mecanical orthostripping permits spectacular and stable corrections, without needing extractions. 16 year old Class II-2 patient (22 months of treatment y 16 appointments).

Fig. 47. Difference in the smile, before and after treatment.

sion in patients with limited gingival exposure, brachyfacial patients and those with a diminished lower third. Where patients have open bite (< 1/3) and with a view to simplifying the biomechanics, we use the same arch wires but with anterior elastics (strong and short) for 14 hours per day. The achieves a posterior intrusion vector which strengthens the action of the other intrusion mechanisms (Palatine Bar, High Pull Traction, etc.). In many patients with severe open bite and posterior vertical excess we prefer to combine the NiTi Curve of Spee ( in a reverse way) with miniscrews at the level of the molars.

Arch wires For mixed dentition we employ the traditional ByPass arches by Dr. Mulligan or RM Ricketts. For permanent dentition we use nickel-titanium preformed curve of Spee arch wires. We differentiate the biomechanics of incisor intrusion and molar extrusion from that of incisor extrusion and molar intrusion by the differential use of elastics.
Fig. 48. The combination of Curve Spee archwires and elastics are an excellent biomechanical solution for the squeletal openbite treatment without surgery. 15 year old patient treated with extractions and SWLF biomechanics for openbite. Class I with anterior open bite. The patient declined orthognatic surgery and we opted for orthodontics to achieve vertical dento-alveolar compensation, extracting the first lower premolars and second upper premolars (this was actually a Class III compensated to Class I by very heavy postero-rotation of the mandible). We basically employed curve of Spee archwires and anterior elastics (to control the posterior molar) followed by rectangular steel archwires and Bendaloy wires with elastics to perform final adjustments to the occlusion. Appointments: 14 Time: 22 months.

Clinical details We recommend that the decision as to which wire and biomechanics we intend to use in levelling should be delayed until after initial alignment, as the initial alignment and expansion notably modifies overbite and the vertical relationships. The use of apparatus to distalize molars (Coil-Spring with crimpable hooks, Wilson 3D Maxillary Bimetric Distalizing Arch, HP Spring-Gear or OrtoflexPendulum) improves the incisal relationship in patients with increased overbite. It is essential to determine the origin of the overbite or open bite and its distinct components (excessive anterior intru172

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Fig. 49. The use of crimpable hooks in .017 x 25 Curve Spee NiTi for the treatment of open bites. 14 year old patient with a dental and squeletal openbite treated without extractions, but with orthostripping and SWLF biomechanics for openbite (curve of Spee archwires, crimpable hooks and anterior elastics). Treatment time 26 months and 18 appointments.

Fig. 50. Posterior miniscrews are a great help in the openbite treatment without surgery of patients in permanent dentition (26 months of treatment and 17 appointments).

sion/extrusion or excessive posterior intrusion/extrusion). The degree of dento-gingival exposure, the facial biotype and the growth tendency are three elements to be kept very much in mind. Open bite usually requires a different and more precise diagnosis than is the case with overbite and occasionally requires more complex biomechanics which are beyond the scope of the issues discussed here.

Space closure
Aims

Closure of the gaps generated by expansion, distalization procedures and extractions in the optimal manner and sequence in view of the final objectives in the case in question. Achieve optimal points of interdental contact with sufficiently paralleled roots and good periodontal health.

arches with pre-soldered hooks. With the SWLF technique, the clinician can place the hooks in accordance with the location and number of spaces to be closed and the preferred level of control over anchorage. In some cases, the pins may be placed asymmetrically (e.g. in order to correct middle line problems) or be used as stops on the arch. Intramaxillary and intermaxillary elastic elements may be fitted to the pins. This system, which has been widely covered in orthodontic literature, is simple to use, very ergonomic and is clinically very efficient. It is important to know how to ligate each of the brackets at this stage: normally in a figure of eight on the incisors and in the centre on canines and premolars. The hook is most frequently placed distally on the laterals.

Finishing
Aims
To consolidate the results achieved in the previous therapeutic stages. To close spaces completely, parallel the roots and control radicular torque. To correct all the positional anomalies of the teeth and to establish definitive points of contact. Detailing and final intercuspidation should be as close as possible to the ideal occlusion.

Selection criteria One of the aims of the SWLF technique is to


encourage the development of the shape of the patients potential arch and to avoid extractions whenever possible. As in other Low Friction techniques the SWLF technique drastically reduces the number of extractions thanks to the effectiveness of thermal NiTi for initial expansion ( light forces stimulate the growth of the alveolar bone) in conjunction with the use of Functional Appliances (functional intermittent forces), the 3D control and distalization of molars and Orthostripping. Many of the spaces we have to close are those previously achieved by molar distalization techniques. The combination of the Synergy bracket with Steel rectangular arch wire and hooks from which to obtain traction with chains, modules or springs provides surprisingly good results in respect of space closure. We design a new kind of multipurpose crimpable hooks that we use to distalization of the molars , open or close the space.

Selection criteria The arch wire of choice for the final detailing of the occlusion is undoubtedly Beta Titanium III, a cutting-edge high-tech wire which combines the best of nickel-titanium and steel. The wire admits bends and final compensation corrections without removing the wire from the brackets and, somewhat surprisingly, without causing discomfort to the patient. Although we could use it as a matter of routine at this particular stage, we actually use it when we require a range of final detailing steps (in-set and off-set correction, inclinations and vertical problems) or we wish to retain torque and the patients biology hinders the finishing process (periodontal patients, combined treatments, etc). As second choice, in very favourable circumstances, we employ stainless steel 8-strand braided arch wires.

Arch wires Rectangular stainless steel arch wires onto which we intraorally place hooks, which have been specially designed for the SWLF technique by means of special pliers Clinical details One of the traditional problems of the SW technique is the biomechanical difficulty of closing spaces with sliding techniques. SWLF resolves the difficulty by improving the system by which the brackets slide along the arch wire and vice versa. The intraoral positioning of hooks is simpler and more versatile than the purchase of a large stock of
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Arch wires

Beta titanium III arch wires, a high quality titanium-molybdenum alloy specifically created for the SWLF technique. Stainless steel 8-strand braided arch wires, as an alternative to the above.

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Fig. 51. Dysfunctional patients treatment attaches great importance to us, but we avoid using complicated diagnostic and therapeutic procedures not based on scientific evidence. Our motto is clarity of the diagnostic concept and maximum simplicity, efficiency and effectivity of treatment. 31 year old patient treated with orthodontic of a TMJ pain and limited movements (26 months of treatment and 17 appointments).

Fig. 52. One of our therapeutic objectives it is to make our treatments as simple and as quick as we can. Many Classes III could be early and simple treated combining Orthopaedics with the Friction Selection Control concept. Squeletal Class III treated with a chincup and SWLF. Treatment time 24 months and 14 appointments.

Fig. 53. The Synergy design and the new thermal wires permit an early insertion of rectangular wires. This means a great advantage in Orthodontic - Orthognatic Surgery treatments. Fig. 54. Patient treated at our Universitys Research and Treatment Service for Dentofacial Deformities. Mixed Class III Facial aspect (A and B) and intraoral photographs before treatment (C), surgical preparation and splints (D). The Synergy bracket and super elastic rectangular archwires make it possible to shorten pre-surgical orthodontics and quick insertion of 19 x 25 archwires with hooks (E).

Fig. 55. The patients Helical CAT scan disclosed asymmetry at the base of the cranium, asymmetry in the glenoid cavity and, unusually, compensatory mandibular asymmetry.

Fig. 56. Appearance after pre-surgical decompensation and cephalometric prediction of the proposed surgery (STO).

Clinical details It is the final detailing and finishing which distinguishes one orthodontist from another. Mistakes at this stage of the treatment cannot be disguised and are clearly noticeable to the patient, and to other practitioners. Some of the

time we have saved by using the SWLF technique for alignment and space closure must be spent on final detailing. It should be considered whether or not the patient or malocclusion tend towards natural intercuspidation in order to

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Fig. 57. The pre-surgical predictions (F) and the post-surgical reality (G) correspond quite closely. Occlusion at the end (H, I) and patients face (J, K).

Fig. 58. Occlusion, intra and extra-oral view one year after treatment ended. No functional problems or relapse can be observed. The patient has gained both functionally and aesthetically, and now enjoys high levels of self-esteem. Even more importantly for us, the patient is a happier person.

Fig. 59. Extra-oral view of the patient before and after the treatment with orthognatic surgery and SWLF Technique.

Fig. 60. Evidence Based Orthodontics (numerous friction articles) proves the high effectivity and the advantages of the Synergy bracket against other conventional and low friction brackets. It can be checked comparing SWLF (and its concept of Friction Selection Control) with other techniques only based on self-ligation and low friction (maxilar right-left).

decide which type of arch to use (braided when the answer is yes and Beta Titanium III when the answer is no and there is still a lot of work to do). We must combine intraoral detailing with profuse use of

short and strong elastics which help to settle the occlusion. If necessary, and the requirements of the anterior and posterior groups are quite distinct, we can cut the upper arch into three segments and apply elastics differentially.

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Fig. 61. Differences between the effectivity of a self-ligating bracket (Damon) and the Synergy on the upper arch of one patient. Similar results are obtained but with a very different cost price.

Fig. 62. My personal experience is that it is not easy to end some cases with some self-ligating brackets because of the lack of radicular control and torque at the end of the treatment. Class II-2 treated in 18 months with SWLF Curve Spee archwires and Damon II brackets (maxilar right side) and Synergy (maxilar left side). When bending Synergy in figure of 8 to a thick rectangular stainless steel wire we obtain an excellent torque control.

Fig. 63. The orthodontic research should try to find the causes of the relapse beyond the quality and kind of treatment. Nowadays we know that the maintenance of the lower intercanine width does not guarantee occlusal or long term stability incisal alignment. Our unique anti-relapse assurance seems to be the fixed retention for life. Who conserve precisely the intercanine width all through the treatment and does not retain it at the end (fixed or removably)?

Fig. 64. Intermittent dentofacial orthopaedics forces combined with light and constant orthodontic forces, generated by the new thermoelastic wires, give us some guarantees of achieving the best arch shape for each patient. SWLF tries to obtain the best smile because a smile is forever as long as, in agreement with the EBO and the studies of Dr. Little, the retention is cemented.

For final posterior occlusal settlement in the last two months of treatment, we recommend using the free wire, i.e., ligated at the centre on the premolar and canine premolars. In short, our SWLF Technique is not simply a bracket, it encompasses concepts founded on scientific evidence, a clear and simple diagnostic system centred on a new analysis of occlusal development and facial growth, a detailed study of the aesthetics of the smile and the face, the dynamic occlusal function and its relation to craniomandibular dysfunctional pathology, temporomandibular joint, the clear and sequential description of objectives and therapeutic solutions and the establishment of protocols for the various treatment options. From the point of view of technique, we have simplified the biomechanics, which has made learning the technique a simple and rational process.

SUGGESTED READINGS
1. Surez Quintanilla D: Tratamiento basado en la evidencia: Paradigma de la Ortodoncia del futuro. Ortodoncia Clnica 3 (3): 118-122,2000. 2- Rossouw E: Seminars in Orthodontics. Sadowsky PL Editor.WB Saunders.9:4, 2003 3 .Surez-Quintanilla D y Canut JA Eine experimentelle Studie der kieferorthopdischen Wurzelresorption an menschlichen Schneidezhnen. Inform. aus Orthod. Kieferorthop. 1: 23- 34, 1997 4. Surez-Quintanilla D, Abeleira MT, Rodrguez MA: Problemos Tribolgicos en el Diseo de Brackets. Rev Esp Ortodoncia 25: 29-45, 1995. 5. Surez Quintanilla D: Nuevos alambres en Ortodoncia. En: A Bascones (ed): Tratado de Odontologa. Tomo II. SmithKline Beecham SA, Madrid, 1998. 6. Surez Quintanilla D :Nuevos brackets y aleaciones en Ortodoncia. En Canut JA: Ortodoncia clnica y teraputica. Masson, Barcelona, 2000. 7- Surez-Quintanilla, D: Clinica e tecnologia dello StraightWire a bassa frizione:il Sistema Synergy. Ortodonzia Clinica. Quintessenza Edizioni. 2004, 3: 37-58.
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ACKNOWLEDGEMENTS
In Orthodontics the difference between failure and success is doing a thing nearly right and doing a thing exactly right Prof. Jos Antonio Canut Brusola We would like to dedicate this article to the memory of our Professor and friend Cucho Canut Brusola.