Use of variable torque brackets to enhance treatment

outcomes
Ralph Nicassio DDS
Many clinicians performing Orthodontics for their patients are missing an opportunity to
get better results because they are using the same standard Roth prescription on the
incisor brackets on every case.
One example of the limitations using standard Roth brackets is simple alignment of a
blocked-out tooth. Evidence that the root has not adequately moved forward can be
seen when the clinical crown is shorter than the contra-lateral tooth. (Fig. 1, 2)

Fig. 1

Fig. 2

For most patients impeccable resolution of this

problem is their chief complaint regardless of
other issues in the case. Resourceful clinicians

Fig. 3

typically attempt to solve this with strategies including bonding brackets upside down or
arbitrarily angling placement to enhance the labial root torque. (Thomas, 09) (Fig.3)
While possibly effective, other compensations are typically required later and it can be
challenging to remember which cases these changes were made on.
Advances in manufacturing technology have produced super-elastic rectangular
nitie wires that can easily and efficiently apply root torque. One such wire is a Super
Elastic NiTi Braid 8, .021x.025 (Ortho Organizers, Carlsbad, CA, USA), that has
approximately the same flexibility as .016N wire. (Fig. 4, 5)

Fig. 4

Fig. 5

In McLaughlin-Bennett-Trevisi, the author reviews Andrews six keys to normal

occlusion. Key 3 is refers to crown angulation and labiolingual or buccolingual
inclination (torque) describing it as follows:
Torque is expressed in plus or minus degrees, representing the angle formed by
a line which bears 90 degrees to the occlusal plane and a line that is tangent to
the middle of the labial or buccal long axis of the clinical crown. A plus reading is
given if the gingival portion of the tangent line is lingual to the incisal portion. A
minus reading is recorded when the gingival portion of the tangent line is labial to
the incisal portion. (Fortini, Lupoli, 89)
A more elegant approach is to select bracket torque prescription designed to best align
the teeth and/or prevent unwanted tooth movements.
Torque is affected only when 2 edges of rectangular wire touch the walls of the bracket
slot. But there cannot be excessive binding such that
arch wires are not permitted to move easily for alignment
and to allow sliding mechanics. (Andrews, 1972)(Fig. 6)
This is a central dilemma of bracket design: friction is the
enemy of some tooth movements such as alignment and
sliding mechanics while it is our best friend for other
tooth movements like
application of torque.
Fig. 6

To balance this dilemma

manufactures machine up to 20 degrees of wire spin when
.019x.025ss wire is engaged into a .022 slot bracket and
6 degrees on a .021x.025ss wire. (Archambault, et al.,
2010) The range of this bracket spin has both A-P and
vertical consequences on clinical outcomes. (Fig. 7) The
ramifications of this are very clinically significant.
For most patients upper incisor inclination would have the
upper incisor long-axis pointing right behind the orbit. In
most cases the treatment objective is to finish with the upper incisors-SN line to
approximate 103 degrees. (Fig. 8)

Fig. 7

Fig. 8

But when retraction forces are applied to upper incisors this quickly results in these
teeth moving to the retraction limit of the bracket prescription being used.
If standard Roth prescription brackets are being used the negative A-P and vertical
consequences to the upper incisors include:

a) de-torqueing (Fig. 9)

Fig 9

b) anterior deep bite (Fig. 10)

Fig. 10

c) increase in gingival display

Fig. 11

And while it is possible to recover from these undesirable results, re-establishing incisor
torque is typically very slow and inefficient. The smarter approach is to prevent the
problems before they occur!
Many clinicians have learned to make skillful compensations to prevent these unwanted
tooth movements. These include adding torque to arch wires or using reverse curve
wires. Even these may not adequately eliminate the retraction limits when using
standard Roth brackets. But simply employing variable torque prescription to the
appliance design can prevent the unwanted tooth movements including de-torqueing of
the incisors.
There are significant efficiency and esthetic advantages in cases requiring upper incisor
retraction to select upper incisor brackets with a higher torque prescription. The range
of bracket torque still has approximately 20 degrees of wire spin (depending on the
manufacture). This is a surprise to many as even rectangular wire essentially acts like a
round wire in diameter until a tooth either proclines or retroclines enough for the edges
to bind into the rectangular bracket slot. (Fig. 12)

This play or slop is needed to permit sliding mechanics but the retraction limit using
these brackets is the ideal upper 1-MP=103 degrees. Positive torque prescriptions
move incisor roots lingually. Negative torque prescriptions move incisor roots facially.
(Ortho Organizers, Carlsbad, CA) (Fig. 12)

Fig. 12

As a clinician it is important to remember that using these brackets often will initially
result in the upper incisors proclining MORE than you are accustomed to seeing during
leveling when using a Standard Roth bracket prescription. But the reward is that the
upper incisors will finish with more ideal A-P and vertical inclination as retraction
mechanics completes. This translates into more ideal results and shorter treatment
time as less recovery of unwanted tooth movements is required. (It must be
emphasized that light forces must also be used during mechanics. Excessive force

could overpower the designed customized torque prescription selected. Orthodontics

remains an art form that requires patience.)
Variable torque prescription is also very important for the lower arch. For example, if
there is crowding in the lower arch and the case is being treated non-extraction the
typical result is advancement of the lower incisors and increased proclination. (Fig. 13)
Fig. 13

To prevent this selecting lower incisor brackets with more negative torque can be
effective in minimizing the advancement. (Fig. 14)
Fig. 14

Non-extraction Class II cases planning to use Class II elastic mechanics also could
benefit from using Negative torque prescription to prevent excessive proclination lower
incisors. This can result in more stability and a better periodontal prognosis. (Fig. 15)
Fig. 15

However, in Class I or Class II cases where lower bicuspids are removed the ideal
lower incisor bracket prescription changes
dramatically!!! The typical problem when lower
bicuspids are removed is that extraction space
closure using lower intra-arch mechanics often are
too much at the expense of the lower anterior teeth
retracting. The results of this can be miserable
including deep bite, increase in gingival display,
clockwise change in occlusal plane, and Class II
finishes. (Fig. 16)
Much of these complications can be prevented by
using lower anterior brackets with more positive
torque prescription. The effect of this is to increase
the lower anterior anchorage to assist closing the
lower extraction spaces by bringing the lower
Fig. 16

posterior teeth forward more than by retracting the lower anterior teeth. (Fig. 15)
Note: if excessive lower retraction is a concern it often additionally is better to extract
lower 2nd bicuspids rather than lower 1st bicuspids.
Ideally in non-extraction Class III cases where upper incisors start out being proclined
as a dental compensation for skeletal Class III it is helpful to use upper incisor brackets
with more negative bracket torque prescription(move the roots labially) to finish with
more esthetically pleasing upper incisors that do not procline the upper incisors further.
(Fig. 17)

Fig. 17

Unfortunately manufactures have resisted providing this prescription due to inadequate

demand from clinicians.
It is the authors contention that far too many cases currently are being treated nonextraction. But when this is done open bite is a common finishing complication of the
upper and lower incisor advancement. Custom appliance design using incisor brackets
with negative torque prescription could greatly prevent open bite complications.
Until bracket suppliers provide upper incisor brackets with negative root torque that
could prevent incisor advancement, excessive upper incisor inclination, and open bite
complications, other strategies may need to be employed. (Fig. 18)

Fig. 18

The problem when deciding which variable torque brackets should be selected is that
many cases have conflicting treatment objectives. For example if the decision has been
made to extract upper teeth ONLY in a Class II case positive torque brackets would
normally be used on the upper incisors. But if there are also blocked-out lateral

incisors, negative torque would best move the roots labially of these laterals while the
upper centrals would get more positively torqued prescription.
The first priority in any case must be to impeccably straighten the teeth and bracket
torque prescription should be selected paramount to achieve this treatment objective.
Secondly, anticipation of any unwanted tooth movements during mechanics should be
considered.
Thirdly the goal is to select upper torque prescription that creates the most ideal
esthetics and lower torque prescription that enables dental compensations when there
is skeletal discrepancy limitations (skeletal Cl II or Cl III).
The most common situations and recommended bracket prescriptions include:
Upper incisors
Negative bracket torque prescription (If they become available)
A) advancement of upper crowding in non-extraction cases
B) open bite prevention
C) advancement of upper incisors in non-extraction cases needing Cl III elastics

Positive bracket torque prescription

A) non-extraction cases where the upper incisor start out being retroclined
B) Class II cases where the upper arch is extracting and the upper incisor will be
retracted
C) Cases where there are gingival display concerns
Lower Incisors
Negative bracket torque prescription
A) advancement of lower crowding in non-extraction cases
B) advancement of lower incisors in non-extraction cases needing Class II elastics
C) Class III non-extraction cases to minimize the lower incisor advancement
Positive bracket torque prescription
A) Class I cases where lower bicuspids are extracted to add lower anterior
anchorage
B) Class II cases where lower bicuspids are extracted to add lower anterior
anchorage

Finally it is important to consider that each stage or orthodontic treatment has specific
treatment objectives:
Stage
Level and Alignment
Mechanics
Finishing

Objective
to straighten the teeth
to effect bodily tooth movements
to detail esthetics and finalize the occlusion

Conclusion:
Perhaps the most elegant Orthodontics would include selecting specific bracket torque
prescriptions that would most efficiently produce superior results and reduce the need to
recover from unwanted tooth movements.
The most complex Orthodontic cases might best be treated by changing bracket
prescriptions at each stage if necessary to optimize results.
For much of the tooth movement 19 x 25 wire and a 22 slot appliance essentially act
like a round wire. Using variable torque brackets creates wire spin limits more favorable
to upper aesthetics and lower tooth compensation.
One of the most sought after topics in Orthodontics is case finishing. Many cases
require excessive time and energy as the clinician struggles to correct unwanted tooth
movements during the treatment. Better case diagnosis and the use of variable torque
brackets in many cases improves outcomes, greatly reduces treatment time, produces
more stable results, enables more intra-arch mechanics, reduces the need for patient
compliance, increases profitability, and increases overall satisfaction of performing
Orthodontics.

BLIBIOGRAPHY
Archambault, A., Badawi, H., Carey, J., Flores-Mir, C., Lacoursiere, R., Major, P. W.
Torque expression in stainless steel orthodontic brackets. Angel Orthodontist.
2010;80:201-210
Andrews, L. F., The six keys to normal occlusion. American Journal of Orthodontics.
1972;62:3:296-309
Fortini, A., Lupoli, M. Orthodontic treatment conceptions according to McLaughlinBennet-Trevisi. Virtual Journal of Orthodontics. 1998;2.3. Retrieved from
http://www.vjo.it/issue-2-3/mbt01n/

Thomas, W. W. Variable torque for optimal inclination. Clinical Impression, 2009;17:1

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