CAAPP

The part of treatment that the orthodontist has control over (other than the treatment plan) is Alignment and Space Closure (ASC). The patient has control over elastic wear to coordinate the arches and finish the occlusion. I looked at 42 consecutively treated patients. 34 were non-extraction and 8 were extraction cases. ASC took an average of 9 months to complete for the non-extraction group and 11 months for the extraction group.

To determine my average treatment time in full braces I looked at my last 145 consecutively debonded patients. The average treatment time from bonding to debonding was 16 months. 78% of patients had an average treatment time of 13.4 months.

Our treatment time has decreased approximately 6 months on average over the years as I became more effiicient and bracket placement became more precise. The short treatment time is also due to the fact that thanks to Xbow we don't put patients in full braces until the buccal occlusion is Class I. The Xbow phase of treatment can add 12 months to overall treatment time if the springs are on for 6 months and you have to expand the maxilla and hold for 5 months.

Combination Active Anteriors and Passive Posteriors (CAAPP) or "All or None Ligation (ANL)" combines early incisor control with ligated twin brackets and decreased resitance to sliding with passive self-ligating brackets on canines and bicuspids, creating a "long buccal tube". Ligated incisors also give the young patients want they ask for, colored ligatures.

The goal of "Incisor Targeting" is to align the teeth as quickly as possible with the lightest round archwire available (currently .012 nickel titanium) ligated to the base of the slot for maximum deflection, and then gain third order control of the incisors with a rectangular nickel titanium archwire ligated to the base of the slot . The .012 niti archwire from G and H has excellent shape memory with little distortion. This achieves the most movement from the lightest force archwire with maximum patient comfort and the least amount of root resorption possible.

There is binding friction due to the archwire contacting the bracket slot as the tooth tips and uprights. Occlusal forces and the "jiggling" of teeth is probably the reason that we can move incisors rapidly with only 50 grams of force from a .012" niti archwire 14 when in theory the 50 gram per tooth ligation binding force should prevent tooth movement with an archwire that light.

Resistance to sliding = binding friction due to angle between archwire and bracket + classical friction + binding friction due to ligatures or a spring clip in an active self-ligating bracket (compared to a buccal tube or convertible buccal tube which is the same as a passive self-ligating bracket and a slightly undersized archwire eg. .017X.025 in an .018X.027 bracket slot)

1973: Dr. Wildman combines nickel titanium archwires and his "Edgelok" passive self-ligating bracket and demonstrates the "tube effect".

1997: Dr. Wildman created the "TwinLok" passive self-ligating bracket which was the basis for all passive self-ligating brackets to follow. This author was asked by Ormco to test the .018 slot version of the TwinLok bracket. The biggest advantage compared to a completely ligated system was reduced posterior binding, even with full size rectangular archwires. This resulted in the CAAPP system.

"Compared with conventional brackets, self-ligating brackets produce lower friction when coupled with small round archwires in the absence of tipping and/or torque in an ideally aligned arch." 18

In an article titled "Self-ligating vs conventional brackets in the treatment of mandibular crowding: A prospective clinical trial of treatment duration and dental effects" Pandis 24 found:

"For moderate crowding (irregularity index less than 5), however, the self-ligating group had 2.7 times faster correction. This difference was marginally insignificant for subjects with irregularity index scores greater than 5. Greater crowding prolonged treatment by an additional 20% for each irregularity index unit."

This is due to increased binding friction between the archwire and bracket slot as the crowding gets worse.

Dr. Badawi 22, with help from the Department of Mechanical Engineering at the University of Alberta has built the most advanced orthodontic simulator to date. It generates real-time 3D displays of forces acting on every tooth simultaneously. They compared passive self ligated brackets to traditionally ligated twin brackets in a high canine malocclusion. "The total resistance to sliding in the brackets posterior to the maxillary right canine was less than the resistance mesial to the canine; this meant that the wire will preferentially slide through the canine, first premolar, and second premolar brackets rather than sliding through the brackets from the maxillary right lateral incisor to the left second premolar." This supports the CAAPP system of brackets.

Dr. Badawi's orthodontic simulator gives us an idea of the effects of ligatures on resistance to sliding.. For a high canine malocclusion and an .018 niti archwire the extrusive forces measured on the canine were 5N to 2N (~509 to 204 grams force) for the PSL brackets compared to 7.68N to 1.16N (~783 to 118 grams force) for the ligated brackets. The labial force on the canine was 0.3N to 0.4N (~30 to 40 grams force) for the PSL brackets and 1.1N to 0.8N (~110 to 80 grams force) for the ligated brackets. This is a difference of 274 grams for the extrusive force and 80 grams for the labial force. The mesial distal resistance to sliding for the ligated canine was 2.45N or approximately 250 grams force which is close to the 274 grams force difference in extrusion (There is a lot of binding friction in a high canine).

Incisor proclination is the first thing that happens when crowded incisors begin unravelling, and it is difficult enough to establish torque control with ligated twin brackets. Drs. Andrews, Ricketts, and Roth had argued over a few degrees of incisor torque. Dr. Roth found a significant difference in torque of the upper central incisor by increasing the prescription only 5 degrees from 7 degrees in Dr. Andrews original prescription to 12 degrees. Dr. Badawi 10,19 at the University of Alberta has shown that clinically effective torque (5 Nmm) begins at 15 degrees for active SL brackets and 22.5 degrees for passive SL brackets with a .019 X .025 inch stainles steel archwire in an .022 slot, even though the engagement angle is 7.5 degrees for active and 15 degrees for passive SL brackets. Ligated twin brackets control incisors better than active or passive self-ligating brackets.

We use G and H niti and heat treated stainless steel archwires. Our niti wires are Eruopa I (Ovoid). We sometimes use the upper arch form on the lower. Our heat treated stainless steel wires are Europa II Platinum Proportion TM in 84%, 92%, and 100%. For very small arches we use either Bioform III (Tapered) or an 84% contricted to an 76% with a turret. The following chart is copied from the G and H website.

The goal of lighter forces is increased patient comfort and decreased root resorption. Clinical tooth movement involves orthodontic forces as opposed to physiologic or natural eruptive forces. We can get an idea of how much heavier orthodontic forces are compared to physiologic forces by measuring root resorption 20. Harris 9 found that the mean cube root volumes of the resorption craters in the light force (25 grams) and heavy force (225 grams) groups were about two and four times greater than in the control group, respectively. In another study from the University of Sydney, Barbagallo 13 found the light-force teeth had approximately five times more resorption than the control teeth. The heavy-force teeth had about nine times more root resorption than the controls. The lightest arch wire available is the .012 nickel titanium which delivers a force of approximately 50 grams or twice what the above studies considered a light force. The .014x.025 nickel titanium arch wire is the lightest arch wire available which "begins to fill" the slot in the edgewise dimension. It delivers approximately 328 grams of horizontal (in/out) force which is greater than the "heavy" force in the above studies. Current orthodontic forces are not physiologic forces, even when an .022 PSL bracket is used with the lightest archwire left in for 20 weeks.

In the "race to fill the slot" we use an .018 slot and "shift gears" only three times, from .012 nickel titanium to .018 nickel titanium, from .018 nickel titanium to .014X.025 nickel titanium, and then to .016X.025 stainless steel. (Dr. Ricketts was doing essentially the same thing when I began studying orthodontics thirty years ago.) If there is a lot of incisor crowding we sometimes use an .014 niti before switching to the .018 niti. We don't pick up the second molars until the .018 niti.

The .022 PSLB technique leaves each niti archwire in for 10 to 20 weeks for a total of 24 to 46 weeks to establish a basic archform. The CAAPP system does the same in 12 to 24 weeks, depending on the amount of crowding. Patients can tell their orthodontist when they stopped noticing tooth movement, both visually and by discomfort. In the author's experience this is approximately 6 weeks or less for each niti archwire. Patients do not like to stretch the treatment time out by sitting in passive archwires. There is also only so much alignment an .012 or .014 niti can do, especially with molars. We have to increase the force to complete alignment and get close to the final archform. The malocclusion is the most stable it will ever be. We artificially change the archform to correct a malocclusion and improve esthetics. The new archform is determined by the archwires, not the tongue. Could it just be the .019 X .025 stainless steel archwire with the broad archform causing that molar expansion? Could leaving a patient in the same niti archwire for 20 weeks have more to do with the management of a large, busy practice than evidence-based orthodontics?

Why would you want archwire play in incisor brackets? How do four incisor ligatures per arch create a negative effect? Choosing colored incisor ligatures may be the most important part of the appointment in the minds of young patients.

The crimpable stops prevent the wire from shifting and causing a long end. We can accomplish the same thing by ligating the incisors. Is it better to control the archwire or the incisors?

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The following is an example of rapid alignment followed by interproximal reduction of the upper and lower incisors.

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The following are examples of rapid proclination and alignment of lower incisors with an .012" nickel titanium archwire in .018" slot CAAPP. This is how we test different bracket types and combinations.

______________________________After 2 months with .012 niti, day of .018 niti placement____After 1 month of .018 niti, day of .014X.025 niti placement

____________________________________________________2 months with .012 niti and elastic chain to canine, day of change to .014X.025 niti

_____________________________________________________2 months .012 niti, day of change to .018 niti to lower second molars

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The following case shows alignment of an ectopically erupted upper left first bicuspid with gingival recession. There were no open coil springs used. We just put the brackets in the right places and let the niti archwires work out. We progressed through round and rectangular niti archwires, beginning with an .012, and working up to an .016X.025 SS.

Day of indirect bonding and placement of .012 niti_________________9 months, day of placement of .016X.025 SS and beginning of "Over and Under" elastic chain space closure. 3 pieces of Ormco ______________________________________________________Generation II chain are used, under the wire from the lateral incisor to first molar on each side, then over the wire from lateral ______________________________________________________incisor to lateral incisor.

Total treatment time 20 months. Ready for gingival graft over the upper left first bicuspid.

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Lower canine Carriere brackets can be difficult to open if the upper canine occludes with the lower bracket and causes distortion of the closing mechanism. A jammed gate can be opened with a composite removing plier.

The following is a bicuspid extraction case showing rapid alignment with an .012 niti and light elastic chain. We did not want to procline incisors with the shallow overbite.

6 weeks later. Day of change to .018 niti archwires and begin light vertical elastics from upper canines to lower canines and first bicuspids.

4 weeks later. Day of change to .014X.025 niti archwires. Continue light vertical elastics. Note incisors are completely aligned before rectangular wires are placed. The rectangular niti wires are used to develop arch form, expand the bicuspids in a non-extraction case, begin torque control, and prepare for the .016X.025 stainless steel archwires

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The above patients are obvious four bicuspid extraction cases. The more difficult cases from a treatment planning point of view are borderline extraction. In these cases we often begin non-extraction and consider extracting four bicuspids late in treatment if there is too much lip protrusion. This adds approximately 6 months to the treatment time to close extraction spaces. The following patient is an example of a borderline extraction case where we did not extract based on lip fullness. Total treatment time was 16 months.

The next patient is an example of a borderline extraction case where we decided to treat non extraction based on the esthetics of the smile, archform, and the deep overbite. The lower archform is constricted so expanding the archform allowed us to treat that arch non-extraction. This may be less stable but permanent retention is probalbly indicated whether we extracted or not. Treating the lower arch non-extraction results in proclining the lower incisors which helps reduce the deep overbite. Expanding the upper arch advanced the lateral incisors to bring them into the same plane as the central incisors which is important for the smile. Treatment time was 19 months.

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The following patient is an example of extreme lower arch expansion in a non-extraction case with deep overbite.

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This next case is a Class I skeletal and dental with severe crowding but retroclined incisors and thin lips. The patient and parent were told that we would begin non-extraction but may need to extract four bicuspids if the incisors were overly proclined or if there were any signs of gingival recession. 16 months into treatment and after closure of space created by interproximal reduction of the lower incisors, the patient and parent were given the option of extracting four bicuspids to retract the incisors. The patient and parent declined incisor retraction. This is essentially lip enhancement by increasing tooth support. A parent's orthodontic history can be useful in treatment planning the son or daughter. Below are the patient's mother's photos and side by sides of the mother and patient. Total treatment time which included surgical exposure of the maxillary left canine was 18 months.

The following photos are of the previous patient's mother who had orthodontic treatment as a teenager.

Patient's mother_____________Patient before________________Patient after incisor proclination

This next case is an example of a Class II division 2 malocclusion with a deep overbite, severe lower crowding, and short lower facial height. The patient originally presented at 10 years old with a labially and palatally impinging overbite with gingival recession of the lower incisors requiring an upper 2X4 appliance with high torque brackets on the central incisors and a lower free gingival graft. The patient returned to the office at 16 years old with concerns regarding the overjet and lower crowding. She was treated non-extraction by advancing the lower incisors which corrected the deep overbite, crowding, and much of the overjet. It also advanced her recessive lower lip to balance the nose, lip, and chin projection.

5 months alignment, .016X.025 stainless steel archwire placement and the beginning of Class II elastic traction on the left side.

9 months full braces, 4 months Class II elastics, bicuspids Class I, continue overcorrection with Class II elastics

10 years old______________16 years old______________Indirect bonding/.012 niti ____5 months alignment

10 years old________________16 years old_________________5 months alignment and lower incisor/lip advancement

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The more difficult cases to treatment plan are the borderline extraction cases or the Class II deep overbite cases with lower crowding where four bicuspid extraction results in upper incisor and upper lip retraction. In 1979 when the author began as an orthodontic resident the Tweed philosophy of treating to an upright lower incisor was still popular and the default treatment plan for borderline extraction cases was the extraction of four bicuspids. Even in a Class I with mild incisor crowding the default treatment plan was the extraction of four bicuspids. We did cephalometric analysis and took photos but the diagnosis was generally made from the models. The cephalometric analysis was used to rationalize the removal of four bicuspids. If the upper incisors were past 102 degrees or the lower incisors were greater than 95 degrees it was called a protrusion case. Proclining incisors was not allowed. If we were treating a case of orthodontic relapse and four bicuspids had already been removed, we took out four more teeth. Mixed dentition treatment often meant serial extraction of c's, d's, and 4's. Fixed orthodontic treatment usually meant space closure.

During orthodontic residency the author was exposed to Drs. Ricketts, Roth, Alexander, and Graber. They showed borderline extraction cases treated by non-extraction, especially in Class II deep overbite cases. Dr. Ricketts was the first orthodontist that this author heard speaking about arch development. He spoke about expanding the maxillary arch with "W" arches and treating the mandibular arch to the maxillary arch. Dr. Ricketts and Roth showed cases treated with a broader arch form which resulted in not only greater arch length but also improved smile esthetics. When the author used these broader arch forms in extraction cases with less than 7mm of crowding there was often still the majority of the extraction site to close after alignment. The author eventually changed the default treatment in borderline extraction cases to non-extraction. You can always remove teeth after alignment but you can't put them back in.

This non-extraction approach was especially important in Class II's with deep overbite and normal upper lip fullness where four bicuspid extraction could lead to long treatment and sometimes remaining overjet if the patient did not wear headgear and Class II elastics well. Chasing lower incisors is a hard way to correct overjet, especially when it is based on the idea that a Class II skeletal pattern should have upright lower incisors. Dr. Casko showed us that upright lower incisors do not usually occur in a naturally compensated skeletal Class II. Bicuspids are the wrong teeth to extract if you are looking for more stable lower incisor alignment. Even Dr. Little showed that the most stable result is when you extract the crowded lower incisors. This still results in chasing the lower incisors in Class II's. Interproximal reduction is done on all crowded lower incisors and all incisors where there are black triangles. The contact is made to extend to the papilla. Lower incisor proclination helped resolve crowding, overjet, and deep overbite. The disadvantage was that it required permanent retention. In order to prevent upper incisor proclination in Class II's, phase one molar distalization was employed in growing patients.

For adult Class II patients that decline mandibular advancement surgery, one option is alignment only and leaving the Class II malocclusion. This leaves the surgery option open for the future instead of extracting upper bicuspids and retracting the upper incisors and lip.

The importance of the airway with respect to obstructive sleep apnea has reinforced the need for expansion instead of contraction in borderline extraction cases. Many orthodontists are looking for early signs of airway obstruction not just for facial growth but also to decrease the risk of snoring and sleep apnea. Space for the tongue may be more important than trying to close a skeletal openbite by extracting four bicuspids, or correcting ovejet by pure upper incisor retraction. Dr. Alan Lowe has advanced the science of sleep apnea more than any other dentist and has shown the importance of opening the airway.

Archform expansion in a non-grower, maintaining the molar width, and then treating the lower to the upper. It is only when the author expanded the upper molars in a non-grower that gingival recession became a problem in some patients.

Even if your default treatment is extraction and you practice orthodontics long enough you will come across crowded dentitions with thin upper lips to begin with or an obtuse naso-labial angle where you "don't want to be that guy" who flattens the profile even more. This is most important in Class II patients with retrognathic profiles and prominent noses. I always think of those cases as mandibular advancement surgery cases where we try not to retract the upper incisors and upper lip. This philosophy goes back to the days when we thought we were growing mandibles with functional appliances and that it was an alternative to surgery in growing patients. The goal was to treat to the upper incisor and upper lip. I soon learnt that there was no comparison between my surgery patients and functional appliance patients as far as chin projection went. It still made me look at the upper lip and naso-labial angle and change my default treatment to non-extraction.

Initially, I warned the patients that there may be some gingival recession and I sent them for periodontal consultations for possible gingival grafts. It turned out I worried for nothing in most cases and I began treating more crowded cases non-extraction, especially Class II's. Even if we were not growing mandibles with functional appliances I was looking for upper molar distalization. This led me to the Herbst appliance and later to Xbow.

It looks like we can get away with some expansion and proclination. Archwire expansion generally results in buccal tipping. This will lead to thinner buccal bone or some boney dehisence but this does not automatically cause gingival recession.

Following is a quote from Dr. Carlos Flores-Mir, Department of Dentistry, University of Alberta, Edmonton, Canada in Evidence-Based Dentistry (2011) 12, 20. doi:10.1038/sj.ebd.6400778:
"Clinicians should not automatically assume that an incisor proclination will generate a correlated gingival retraction."
"While not discussed specifically, presence of gingival retraction before orthodontic movement, poor oral hygiene, gingivitis and/or a thin gingival/bone biotype in addition to proclination of incisors will likely produce some degree of gingival recession."

A definition of orthodontics may be "the art and science of tipping teeth to compensate for the malalignment of the jaws".

My patient population was mostly Northern European and South Asian, many with Class II malocclusions with retrognathic mandibles and prominent noses. These were the exact profiles where I did not want to retract upper lips by extracting upper first bicuspids. Even though I was not growing mandibles I wanted to share the Class II correction between the upper and lower, instead of purely retracting the upper. I was happier with my results when I switched from treating to an upright lower incisor to treating to a properly supported upper lip.

The author still uses serial extraction, but usually only in severely crowded mixed dentitions where the lower lateral incisors are impacted or completely blocked lingually, and the overbite is shallow. Sometimes it is best to postpone extracting four first bicuspids, and instead place a lower lingual arch, let the jaws, nose, and chin grow, and let the teeth erupt crowded. The plan for the lower arch might change to non-extraction, especially with a deep overbite, or the extraction of second bicuspids instead of first, epecially in a Class II or shallow overbite, or the extraction of two lower incisors.

As far as the argument of extraction cases being more stable than non-extraction cases it is the author's experience that all crowded cases require permanent retention. As we are often changing the arch form and moving more than just front teeth the author uses removable Essix retainers worn nightly indefintely.

The author has also found Essix retainers to help with bruxing in some TMD patients. If this does not help then an upper wraparound Hawley retainer with a disclusion element against the lower Essix is used. It was Dr. John Thompson from Northwestern University Dental School that taught the author to examine every patient's temporomandibular joints and to use posterior disclusion to decrease contraction of the elevator muscles. The author has found that full coverage splints do not decrease elevator muscle fatigue in many bruxing or clenching patients. If the anterior disclussion acrylic is carried over the upper incisors there can be some upper incisor intrusion.

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Class II patients with retrognathic mandibles who want increased chin projection undergo combined orthodontic-orthognathic surgical treatment. In these patients presurgical orthodontics decompensates the retroclined upper incisors and proclined lower incisors. This often involves the extraction of two lower bicuspids only to allow retraction of the lower incisors and lower lip. This positons the lower lip over the chin to decrease the need for an advancement genioplasty and maximize the mandibular advancement. It leaves the upper second molars unsupported and the molars in a Cl III relationship but allows an ideal surgical result. The following patients had their surgery performed by Dr. William McDonald. Dr. McDonald and I have been treating mandibular advancement patients like this since the 80's. In the following patient the upper incisors were decompensated which made space for the crowded canines, intruded the incisors to decrease the gingival display, support the upper lip, and bring the incisors labially for ideal smile esthetics.

The following patient had proclined upper incisors but the upper lip position was good. The lower arch was decompensated by the extraction of two bicuspids only and space closure to keep the lower incisors upright and the lower lip over the chin. The anterio-posterior step between the upper and lower lips makes this patient an ideal surgical candidate. The same step between the lips would make this patient a poor candidate for Class II compensation by upper incisor and upper lip retraction which would emphasize her nose.