Tip edge technique /certified fixed orthodontic courses by Indian dental academy

Tip edge technique
INDIAN DENTAL ACADEMY
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www.indiandentalacademy.com


Contents
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Introduction
Tip edge concept
Tip edge brackets
Tip edge auxiliaries
Differential Straight Arch Technique
Stages of treatment
Final Finishing
Conclusion
References


Introduction
Since the 1900 Angle introduced various
appliances :
 Angle’s E-arch
 Pin and Tube appliance(1910)
 Ribbon arch appliance (1915)
 Edgewise appliance(1925)


Edgewise appliance
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Labially facing horizontal slot
3-dimensional control over tooth
Very high forces were used
Anchorage depends on extra oral forces
No provision for closure of posterior spaces
Arch wire slot restricts the anteroposterior
correction of dental arches


Begg appliance
During the early 1930s, P.R Begg reverted to the use of
ribbon arch brackets Permitted free tipping followed by controlled uprighting
 Use of round wires
 Use of differential forces(2 oz)
Demands on anchorage units was reduced
However the vertically facing slot had the following
limitations:
 Hindrance in manipulation
 Reduced mesio-distal control



Straight wire appliance




1970s Dr Lawrence Andrews introduced the
Straight Wire “bracket system”
Concept of Preadjusted applianceTip, torque, in-out compensations for each
tooth was available.




Limitations of conventional Straight Wire
bracket






Moving teeth apex first generates maximum
anchorage resistance
Torque control - unwanted reciprocal torque reaction
in adjacent teeth
Full expression of torque not achieved- “torque slop”
due to play between bracket and arch wire


Tip edge concept






Peter C Kesling decided to
combine both the techniques
Modified a straight wire
bracket ,to create Tip Edge
bracket
Technique was first
introduced at the KeslingRocke Orthodontic
Centre,Westville,Indiana,USA
in 1986.


Differential force technique: initial crown
tipping followed by controlled root uprighting
with straight arch wires (differential tooth
movement with straight arch wires).
Therefore it is known as the “Differential
straight arch technique”
Arch wire slot permits initial crown tipping
mesially or distally and faces horizontally, the
slot and bracket are termed “Tip Edge”



Features of tip edge appliance
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Labially facing arch wire slots –improved
manipulation with elastomeric ties
Light forces(2 oz)
Reduced strain on anchorage
With a rectangular slot ,a 3-D control was afforded
Slots open and close during treatment for maximum
ease of arch wire change and minimal discomfort
Facilitated intrusion of teeth.


Tip edge brackets
Kesling determined that :
 It is necessary for each tooth to tip
either mesially or distally –not both
directions
 All teeth tip distally except those distal to
the extraction sites-which tip mesially
 Anchor molars should remain upright
throughout Rx.




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Diagonally opposite corner were removed
Permits desired distal crown
tipping
Preadjusted in 3 dimensionstip,torque,in & out built in
Slot size-0.022”x0.028”


Central ridge
Lateral extensions
Uprighting surface

Tipping surface

Occlusal view

Profile view


Design features

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


Slot size: 0.022”X0.028”
Vertical slot: 0.020”x0.020”- to accept rotating or
up righting springs, power pins ,jigs etc. Both the
gingival and incisal ends are chamfered to facilitate
the insertion of auxiliaries from either direction.
Lateral extensions- for rotational control hidden
behind the arch wire –which is esthetic.
In and out compensation-eliminates the need for
lateral, bicuspid or molar offset
Torque built in base
Tip built in face




Slot permits initial M-D tipping ,this prevents bowing
of arch wire during retraction/space closure and
automatically enhances anchorage.



Uprighting surfaces of the slot determine the final tip
angulations reached with an uprighting spring.
These surfaces can also control torque if an
edgewise arch wire is used.


Types of bracket
Narrow metal tip
edge bracket

Twin metal tip edge
bracket

Narrow ceramic tip
edge bracket


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Twin version of bracket - 018” or 022” slot
size
Known as “Freedom brackets”
Disadvantages :
Unaesthetic
Extra bulk-occlusal interferences and accidental
debonds
Mechanical disadvantage when Side Winder springs
are added.


Tip edge brackets for first premolar extraction cases


Tip edge brackets for second premolar extraction
cases


Tip edge brackets for non extraction or first
molar extraction cases




Preadjusted in 3 dimensionstip,torque,in & out built in

Tip and torque values for maxillary brackets


Tip and torque values for mandibular brackets


Placement of tip edge attachments


Positioning jigs used for bracket placement

Positioning jigs used for bracket placement

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Mid crown position is
recommended (Parkhouse)
Bracket should be aligned
with it’s vertical axis parallel
with the long axis of the
tooth
Mesio-distally at the
midpoint
Height of the bracket should
be at vertical midpoint of the
fully erupted clinical crown




Jigs can be modified by
cutting off the
horizontal section
leaving only straight
vertical markers


Rationale behind a mid crown bonding
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Prescribed torque value in the bracket base is effectively
expressed
Initial tipping will be more by the incisal placement of the bracket
but it also requires an increased amount of root uprighting
Side Winder springs are placed at greater mechanical
disadvantage if the distance between the point of rotation and the
root apex is increased—resulting in loss of eficiency
Also mid-crown position reduces occlusal interference therefore
decreases the number of accidental debonds.


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Molar tubes

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Parallel to occlusal surfaces
Upper molar tubes placed at the same level as the
bicuspid


Universal premolar tip edge
brackets
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Similar tip and torque for 1st
and 2nd premolars
So, possible to have just 2
upper and 2 lower bicuspid
brackets.
Can be switched from R to
L side to provide clockwise
or counterclockwise crown
tipping.


Identification of brackets
 Arrow - direction of tipping
 Premolar jigs are modified
by the addition of a 90°
angle at the tip of the jig
which indicates the direction
of tipping
 Origin from Queen’s
University ,Belfast –called
as “Irish jigs”


Auxiliaries used in Tip Edge
Technique
1.Molar tubes
Keep molars upright and permit free sliding of arch wire.
Three types:
 Single round tube with torquing flap
 Combination edgewise(0.022”X0.028”) and round
tubes(0.036”)
 Combination edgewise and flat oval tube for increased
bucco-lingual control



Single round tube with torquing flap

Combination of rectangular and round tube

Combination of rectangular and oval tube


Rectangular slot is at the same level as premolar
brackets.
 Permits the placement of straight arch wire
 Round tube dimensions:
0.036”inside diameter,0.250”length
Rectangular tubes are of Easy-Out R TP design with the
posterior inner lumen slightly flared towards the occlusal.
Facilitates archwire removal when a cinchback has been
used



2.Tip edge rings
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Elastomeric rings designed
to function with tip-edge
brackets
Designed to retain archwire
and prevent mesial and
distal tipping during Stage
III
Lingually facing lug on
either end of the crossbar
wedge between the
archwire and the bracket to
control mesiodistal
inclination of the tooth

Straight Shooter (ligature
gun)


Advantages
Less time consuming
Places less pressure on
the tooth ,more
comfortable for the
patient


3.Rotating Springs
 For correction of
rotation
 Preformed from 0.014”
wire
 Inserted from gingival
aspect


4.Mesiodistal uprighting
springs
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Optimal means to upright to
upright teeth mesiodistally
Standard and Side-winder
designs
Provides localised tip
control of individual teeth
without archwire
modification
Fabricated from 0.014”
archwire


Side-winder springs
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Coils rest on the labial
surface of the bracket
Improves:
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Esthetics
Hygiene
Choice to insert from
gingival or occlusal aspect
Mechanical advantages as
centre of the coil is
concentric with the centre of
the bracket


Invisible Side Winder
springs


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Wire of spring lies on archwire
and bracket
Advantages:
 Retained in position by the
elastomeric module, in
addition to it’s own spring
pressure
 Enables modules to be
changed if necessary,
during the root uprighting
process without removing
springs




Because bulky
hook has been
eliminated, spring
arm has a wide
range of activation


Direction of insertion



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Occlusal and not gingival
Masticatory forces coming occlusally are deflected
harmlessly off the coils of a correctly inserted spring,
keeping these in close proximity to the bracket face.
If inserted from gingival, occlusal forces might distort
them labially away from the bracket –spoils the
action of the spring as well as causes discomfort


Identification of spring


Spring arm points in the
direction towards which
the occlusal tip will
rotate


5.Bilevel pins
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Used to capture auxiliaries
behind tie wings of the
bracket
Heads of pins function to
retain the auxiliaries and to
tie ligature
When used with open coil
spring; eliminates the need
to use vertical loops or to
remove main wire to
remove coil.


6.Power pins
 Ideal auxiliaries to engage
elastic or elastomeric
 Can be inserted from
occlusal or gingival
 Low profile head with 15°
inclination reducing the
need for right and left pins
 Can be inserted or removed
while both ligature and
archwires are in place


7.E-links
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Elastomeric links
stamped from thermoset
material
Less hydrophilic than
thermoplastic material
Available in graded
lengths
E1to E4 smaller size with
no tabs
E4 to larger sizes with
tabs


8.Archwires
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U/L 0.016” round ,hard,resillient wires
Vertical loops may be bent into the initial wire
Small segment of co-axial wire
0.014” or 0.016” NiTi as auxiliary wires for alignment
Advantages:



Rapid anterior bite opening and improve molar control
Reduces the number of archwires required to treat a
specific case




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0.022” S-S used during space closure and final
uprighting or torquing
Rectangular archwires retained in brackets with tipedge rings offer the final expression of tip and
torque predetermined in the bracket slot
0.0215”X0.028” S-S archwire are preferred for final
finishing


Concept & Function
Bite opening




Tip-edge slots facilitate intrusion of teeth along the path
of least resistance without creating lateral root
movements—open deep bites without the need for extra
oral forces
Intrusive forces from: Properly bent 0.016” high-tensile
S-S wires,
 Use of Light inter maxillary elastics(2oz).




Retraction and Space closure without loss of
vertical control




Binding between slot and archwire
In the canine area incisal deflection of
wire




No binding or incisal deflection of wire in tip
edge slot


Dynamic arch wire slot
Tip edge slots become larger as the teeth tip.
The vertical dimension within the slot
continuously increases with each degree of
distal tipping.


Inter bracket distance
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The tip edge bracket
provides automatic
mesiodistal tip control
The tip edge bracket with its
propeller shaped archwire
slot can provide 100%
interbracket distance in both
planes.
As the crown is tipped
distally, slot size increases,
this permits passive
engagement of full size S-S
wire with zero flexing.


Advantages
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No binding or archwire deflection during retraction
Ease of stepping up of archwire size
No inadvertent mesial or distal root movement
Ease of placing rectangular archwires when third
order discrepancies exist between archwire and slot.
No need to use NiTi archwires to avoid discomfort
and accidental debonding




“The Hammock Effect”

When a ligature (especially
steel) is used to retain the
archwire a “hammock
effect” is created that tends
to parallel the archwire with
the gingival and occlusal
edges of the tie wing tips.
This could influence mesial
/distal inclinations
Steel ligature when tied loosely
minimizes the hammock
effect.


Anchorage consideration
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Extra oral anchorage is not required with Differential
Straight Arch Technique
Forces are so light that adequate anchorage can easily
be formed within the mouth.
Binding (as in edgewise slots) is nonexistent during
retraction.
In DSAT,archwires move distally with anterior teeth
retraction and premolars are not bracketed during Stage
I. Therefore no sliding friction occurs---no additional
strain on anchorage.
Only friction is in molar tubes which is minimal because
tubes are long with large diameter.




Axial inclination control
Controlled root movement which is

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Selective
Physiologic
Predetermined


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Selectivity

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Selective axial tooth control w.r.t time and location
Tip or torque is achieved by addition of SideWinder springs to the teeth requiring correction
Rest of the teeth are left undisturbed
Application of force is selective and adjacent teeth
are not “round tripped”
Promotes stability and patient comfort




Limitation


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Design of the bracket automatically limits the
degree of M-D uprighting
Uprighting continues until the control surfaces
within the slot strike the upper and lower surfaces
of the archwire.
Torquing is also limited and ceases even though
the spring remains active-determined by the
torque built in the bracket




Physiologic


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Light and continuous forces are transmitted
through the auxiliaries
Design of tip edge bracket prevents delivery of
high third order torque forces from flexed
rectangular wire


Advantages of Tip Edge brackets


Over conventional edgewise brackets
 Eliminates undesired force couples to promote rapid
bite opening and prevent midline discrepancies
 Anchorage problems are eliminated as space can be
closed with light forces and minimum wire deflection.
This results in diminished anchorage demands and
increased vertical control.
 Permits free crown tipping followed by controlled
uprighting
 Can reposition teeth and jaws with light forces and still
maintain total control over their final positions.




Over Begg brackets
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Horizontally facing archwire slots facilitate initial archwire
engagement especially on rotated teeth. Elastomeric ties provide a
cushion or flexibility that enhances patient comfort and reduces the
chances for bond failure
In –out compensation eliminate the need for molar (or other)
offsets.
Slot designs causes automotive shift from tipping to bodily
movement at the predetermined angle and increase anterior
anchorage to encourage mesial movement of posteriors –
“Programmed Differential Mechanics”
Labio-lingual root torque from rectangular wires possible.


Three stage of Treatment
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Stage I
Objectives
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Open (or close) the anterior bite
Eliminate anterior crowding
Close the anterior spaces
Overcorrect the rotated cuspids and bicuspids
Correct posterior cross bites
Correct any mesiodistal malrelationships of the
buccal segment as necessary


Stage I archwires
 0.016 S-S wire
 Preformed wires




Fabricated from 0.016”
Bow flex archwires
These are size graded
according to the distance
in mm between the
cuspid circles


Intermaxillary circles




Bent in a vertical plane or inclined slightly labial
located 1mm mesial to canine bracket
Anterior portion of the circle is labial to the archwire to facilitate
engagement of distally directed ties or elastics

Advantages of cuspid circles:

Easier to bend

Can be rolled mesio-distally

Less chance of breakage
Disadvantage:

Less retention of elastic if bent too small or tightly


Cuspid ties




Prevents canine from
sliding distally along the
wire
Not to be used when
aligning crowded anterior
teeth with co-axial or NiTi
sectional wire




Bite opening mechanics





Anchor bends placed mesial to molars
If reduced overbite or an open bite is present at
the start of the treatment, reduced degree of
anchor bends are placed.
Also depends upon the angulation of molars-if
molars are tipped mesially, reduced angulation
required.


Intermaxillary elastics




Use of light Class II elastics (1 to 2 oz)
 Worn full time from upper cuspid circles to the distal
ends of lower arch wire or from molar hooks
Overbite reduction is more effective with a more distal
application of elastic to the molar which better resists
distal crown tip and encourages fuller expression of the
anchor bends to the anterior segment




Outrigger appliance

To encourage elastic wear
Auxiliary is threaded over an
archwire formed with
appropriate bite opening
bends or sweeps but no
intermaxillary circles
Has two elastic hooks that
extend labially when
elastics are not engaged
Hooks act as a painful
reminder




Stage II



Objectives:

1.Close any posterior spaces
2.Maintain all corrections obtained during stage I
Edge to edge relationship of anterior teeth
Anterior space closure
Over rotated cuspids and or bicuspids
Corrected mesiodistal molar relationship




Stage II archwires

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



0.020” or 0.022” hard round S-S wire
Reduced anchor bends
Molar offset (vertical) to compensate for the more
gingivally placed round tube
Heavier archwires function as retainers to maintain
arch form and bite opening achieved during stage I
Heavier wires can better withstand the forces of
occlusion-less likely to get distorted










Remove anchor bends,
place sweep in the
archwire
Upper- increased Curve
of Spee
Lower- Reverse Curve
of Spee
Insert wire into
rectangular tube
(Parkhouse)


Derotation of molar
 1mm Molar offset and
10°toe-in for final visit
of stage II
 Initial stages no need to
place these bends as it
increases friction


Leveling of molar








Tipped back molars should
be leveled to allow the
placement of rectangular
archwires
Antitip bend of 10° opposite
premolar-molar contact
point.
Ensures seating of the
distal cusp of tipped molars
Can be combined with
offset and toe-in.


Space closure
 By E-links form buccal
hook on the first molar
to cuspid circle
 Available in graded
lengths
 Usually E-6 or E-5 is
selected




Putting on the
brakes:

Available space can be
closed by protraction of
the posterior teeth
mesially :
a. Application of passive
uprighting spring on the
canine,
b.Tipping surface of the tip
edge arch wire slots
striking the archwire
c.Use of rectangular wire




Automatic canine rotational control during
retraction




Forces are not applied labial to the surface of
canines.
Instead pressure is applied at their contact point
with the lateral incisor


Stage II checks










Intervals 6-8 weeks
Observe space closure
Cut distal ends
Check molar widths
Labial segment position and inclination excessive
Check midlines
Check interarchrelationship
Avoid overcompression




Pre Stage III










To align the premolars
Rotate anchor molars
Level the occlusal plane
Original 0.016 round archwire is used
Increased flexibility helps to level occlusal plane
and elevate premolars
Light lingual elastomerics to derotate molars
Duration-- 6-8 weeks





Stage III
Objectives:




Maintain all corrections achieved during stage I
and stage II
Achieve desired axial inclination of all teeth
M-D inclinations are corrected by use of uprighting
springs
Lingual or labial root torque is achieved through torquing
auxiliary
Tip edge rings maintain and/or influence teeth in final tip
angulations










Stage III archwires
0.020” or 0.022” hard round S-S
wires- to counteract the reciprocal
forces generated by auxiliaries
Heavy wire functions as retainer
Separation of root moving forces
from the archwire permits the
precise application of torque and
uprighting pressures
Maxillary archwire

slight constriction is placed in
the archwire (except in RME
and class III malocclusion)

No anchor bends but a
gentle curve of spee is given to
deliver a gingival force


Maxillary archwire



Mandibular archwire
 Slightly expanded
 Slight anchor bends or
Reverse curve of spee
 Vertical offsets to
compensate for the level
of molar tube
 In class III Rx –widen the
maxillary arch and
narrow the mandibular
 Cuspid ties are normally
not used to allow
uprighting of teeth to take
place.


Mandibular archwire





Stage III Auxiliaries
Torquing auxiliary






Conventional torquing
auxiliary
Torque bars
Curved ribbon sections of
0.022 X0.028” Ni Ti
formed with 20° of
torque.
Individual root torquing
auxiliary

Nickel titanium torque bar

Individual Root Torquing auxiliary



Deep Groove
brackets









For use with torque bars
On the maxillary central
incisors
Conventional preadjusted
edgewise slot cast into the
bottom of tip edge slots.
During stage I and II ,cap
fills the groove
In stage III,cap is removed
and the torque bar is ligated
tightly into the Deep groove
under the round archwire.


Uprighting with Side Winder springs


Third order movement by second order force from a Side
Winder spring in the presence of a rectangular archwire




Indications for rectangular archwires





First proposed by Richard Parkhouse
Simplifies treatment and increases stability during
all uprighting and torquing procedures
To establish molar root torque




Preparation for rectangular Stage III








After completing stage I, 0.016” wire is modified with
vertical curvatures instead of anchor bends ,to avoid the
use of vertical offset
Wire is inserted into the rectangular tube instead of round
tubes. This elevates premolar brackets to the level of
rectangular tube
If premolars are too gingival –initially place the wire into
round tube, then into rectangular tube.
Once premolars are aligned ,shift to 0.020” or 0.022” round
wire


Rectangular stage III wire
 0.0215”X0.028”
rectangular archwire
with similar curvature
as in round wire
 Crimpable hooks are
placed midway
between canine and
lateral incisor brackets
facing gingivally








Mild Curve of spee in maxillary archwire and RCS in
mandibular archwire
If initial open bite or reduced overbite, flat archwires
are made
Compensatory buccal crown torque in anterior
segment to restore zero torque




Pretorqued archwire



0.0215” X 0.028” rectangular archwire with lingual
crown torque (5° maxillary,8° mandibular) for deep
bite cases
Centre line markings:



Black—maxillary
Red--mandibular




Round or Rectangular archwires??






Severe anteroposterior discrepancy round wires
for stage III
Also when molar torque or selective labiolingual
root positioning of canine or mandibular incisor is
not required
Rectangular wires should not be used until the
torque has been established by use of torquing
auxiliary




Final finishing







Use of rectangular wire during this stage
Beginning with 0.019”X0.025” ,then 0.021”X0.028” for total
tooth control.
Rectangular wires should pass through the rectangular
tube
Tip edge rings can maintain or even capture the tip angles
in all bracket slots

All stage III objectives ,especially anterior root torque
must be entirely completed before going to
rectangular finishing archwires


Second molar alignment
 During Stage III, preliminary
alignment by a simple
sectional device suggested
by Dr Tom Rocke.
 Straight 0.016”high tensile
S-S sectionals
 It runs through the channel
of the gingival tie wing of
the first molar, without being
attached to it.
 Mesially ends with a small
occlusally inclined loop
which hooks over the main
archwire

Occlusal seating
 0.019X0.025” braided
archwire and seating
elastics



3 weeks later


Sectioning the main archwire





Cut distal to each canine
Molars and premolars, canine to canine tied
together to prevent spacing
Light rhomboid elastics to allow settling of buccal
section


Tooth Positioners
Pre-Fit positioners come
in different sizes (for
extraction and nonextraction cases)
Inappropriate for
individual tooth size
discrepancies


Conclusion






The tip edge bracket provides varying degrees of
tooth control not previously available in an edgewise
type bracket.
Control ranges from a simple one-point contact and
100% interbracket distance with a round archwire to
predetermined control in three planes with
rectangular arch wire and a Tip-Edge ring.
It also offers advantages over ribbon-arch (Begg)
brackets through ease of manipulation provided by
the horizontally facing slot plus predetermined
limitation of initial crown tipping and control of final
root uprighting.





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References
Tip Edge guide and the Differential Straight Arch
Technique. Peter C Kesling
Orthodontics by Graber Vanarsdall.
Tip Edge Othodontics.Parkhouse
Dynamics of the Tip-Edge
bracket.PeterCKesling.AJODO1989;96:16-25
Treatment with Tip-Edge brackets and Differential
tooth movement.KeslingPC,Rocke
TR,KeslingCK.AJODO1991;99:387-401
The Tip –Edge Concept:Eliminating Unnecessary
Anchorage Strain.Kesling CK.JCO1992;26:165-178.


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