‘The phenomenon of Low Friction Techniques: State of the Art’.

®
The Damon System
–
Simplified Mechanics

Written by Dr. Alan Bagden, D.M.D.

® The Damon System is a registered trademark of Ormco Corporation.

 Dr. Alan Bagden
Dr. Bagden graduated from Lafayette College in 1975 and was accept-
ed at the prestigious dental school of the University of Pennsylvania.
After fulfilling a military obligation with the United States Public Health
Service, he was accepted as an orthodontic resident at the University
of Maryland. In 1987, he joined the practice of Dr. William Wallert.
The two worked together for 10 years, when Dr. Wallert chose to de-
crease the amount of time spent with full-time patient care. During his
career Dr. Bagden has been recognized for his commitment to efficient
treatment and has authored many research articles on this topic. In
2000 Dr. Bagden performed clinical trials and research on the Damon
System of orthodontic treatment and concluded that it was the most
efficient type of orthodontic treatment available. He then began work-
ing closely with Dr. Damon to further refine the technique and has
been instrumental in advancing use of the Damon system within the
orthodontic profession. Dr. Damon and Dr. Bagden conduct seminars
worldwide instructing doctors on the proper utilization of the Damon
system. It is Dr. Bagden’s firm belief that the Damon system of ortho-
dontic treatment will become the industry standard system of treat-
ment by the year 2010. In addition to his clinical involvement with this
project Dr. Bagden is also Board Certified by the American Board of
Orthodontics, an honor enjoyed by less than one quarter of all ortho-
dontists in the United States. He has served as President of the Virginia
Association of Orthodontists and the Northern Virginia Dental Society.
He has been inducted in the Pierre Fauchard Honorary Dental Society
and the American College of Dentists in recognition of his contribution
to the profession. Dr. Bagden is a frequent lecturer at the University of
Maryland Orthodontic Residency program and the National Children’s
Hospital Center Orthodontic residency program.

2
‘The phenomenon of Low Friction Techniques: State of the Art’.

The Damon® System – Simplified Mechanics

The Damon System pf passive self-ligation is an orthodontic technique 7). Place chains for space consolidation under the arch wire to mini-
which utilizes the advantages of a bracket that allows for less binding, mize binding and friction.
and as a result, more effective sliding mechanics. The System is made 8). Move teeth in groups rather than individually. Maintain constant
up of three parts. The first and basic premise, of the System is as fol- blood supply to all teeth; leave no tooth alone and not incorpo-
lows: When the elastomeric modules of traditional orthodontics are rated into the arch wire. Use no single tooth retraction. Don’t coil
applied, a restrictive component of the wire attempting to slide along a tooth and not ligature tie it to the archwire.
the bracket is introduced. When these elastomerics are removed, teeth 9). Close spaces on pre-posted steel arch wires in the final phase of
can slide along the wire with greater ease and efficiency. Secondly, treatment. Finish cases (arch form and detailing) in rectangular
the Damon System has successfully combined the concept of a pas- TMA or steel arch wires. Steel wires are .016 X .025 or .019 X
sive self-ligating bracket with modern high technology arch wires. The .025. TMA wires are .017 X .025 or .019 X .025.
most common of these wires are alloys of Copper and Nickel Tita- 10). Class II and Class III elastics extend from the posts on the final
nium (CuNiTi) and Titanium Molybdenum Alloy (TMA). The spe- arch wires to the first molars. Use two 5/16 in., 6 oz. elastics at
cial properties of these wires also assist in delivering consistent, light night in difficult adult cases.
forces throughout the duration of treatment. For instance, TMA is a 11). Modify the final arch wire for each individual patient based on the
bendable, permanently deformable wire which exhibits up to 1/3 less arch form developed by the balance of forces. This form is estab-
force than stainless steel when compared to same wire dimensions, lished at the end of the high technology arch wire phase (second
i.e. a .019 X .025 TMA wire will deliver approximately one third less phase) and is typically based on the lower arch from.
force than a .019 X .025 stainless steel wire. CuNiTi, in normal use, 12). BE PATIENT! Things can go slow and then happen all of a sud-
will not permanently deform, which gives it the advantage of deliver- den.
ing consistent light forces which can range from less than 100 to more
than 300 grams of force. When CuNiTi is used as an initial wire, the Obviously time has elapsed since this initial composition, but the
forces delivered can be below what the restrictive force of the oppos- understanding that the Damon System is unique among most ortho-
ing orofacial musculature can be. As a result, the expected flaring of dontic techniques in that specific aspects MUST be followed in order
crowded incisors seen in traditional orthodontic delivery systems is to consistently deliver outstanding results has not changed at all. In
not observed. To the contrary, lateral development, rather than incisor fact, following the protocol remains an essential key for success. One
proclination, is observed. The third component of the Damon System can not simply acquire Damon System brackets, apply them in a ran-
is a simplified, logical, treatment protocol. Low friction/ light force dom fashion, use any traditional mechanics an operator desires and
orthodontics means more than just a passively ligated bracket, it’s a then expect to achieve superior results. It just does not happen this
whole philosophy that embraces mechanics, forces, biology and the way. With this thought in mind this chapter will present what is now
high-tech materials to aid in accomplishing excellent results. believed, as I enter my second decade in Damon therapy, as those
elements which are essential for success. While these components as
I have always felt that to achieve consistently high standards, the fun- designed to guide and assist the practitioner on a path to success, they
damentals of a low friction system have to be fully understood. Certain not alone in providing the matrix for excellence. Many of them are the
aspects of treatment are essential to success. For this reason I com- same “pearls” from the original list, others are new and more detailed,
posed “The Twelve Pearls of Damon Treatment” in 2003 which were while still other components of treatment are more arbitrary, but when
those treatment particulars that I believed practitioners should follow delivered with an understanding of what constitutes sensible Damon
at the time; those essential treatment specifics which would lead any mechanics, are just as valuable.
practitioner to success with the Damon System. They were:
Personally speaking, I came from a .018 system before I switched
1). Vary torques in initial prescription to achieve optimal results to The Damon System because conventional wisdom at the time (the
2). Always bond second molar to second molar to facilitate bite 1980’s) was that .018 systems delivered lighter forces than .022 sys-
opening and rotational control. Take a panorex after the rectan- tems. . My thought at that time was that forces delivered through a
gular Damon Copper NiTi phase (the second phase of treatment) small slot would be lower than those delivered through a larger one
and reposition any improper bracket placements. due to the fact that smaller wires were used with the .018 system. In a
3). Always start with an initial .014 Damon Copper NiTi archwire past era of stainless steel based wire technology, this was perhaps the
which is left in place for a ten week period. situation. However, with the advent of NiTi, and especially CuNiTi,
4). Place stops (crimpable or flowable composite) on the arch wire this perspective has dramatically changed. Stainless steel wires thrived
anterior to the crowding …this is usually between the central inci- on larger interbracket distance and small dimension wires. NiTi wires,
sors. due to their extreme flexibility, perform quite well with smaller in-
5). Develop the lateral dimension through archwires and balancing ter bracket distance and, as mentioned above, due to their low forces
the orthodontic forces with facial musculature rather than insert- delivery actually perform better in .022 systems. The Damon System
ing high forced rapid palatal expansion appliances. synthesizes all of the above, as the largest wire utilized is .019 X .025.
6). Deep vertical bites can be opened using different options bases on A .019 X .025 wire in a .022 X .028 bracket allows more freedom of
lower arch requirements. movement within the bracket lumen (i.e. more “play” in the bracket)

3
and when combined with early light CuNiTi wires has the distinct ad- of orthodontic case management, the Damon System suggests
vantage of delivering extremely light initial forces. that each practitioner invest considerable time and energy into
adequately diagnosing each patient’s case prior to initiating treat-
Early in my trials of the Damon System I desired to test whether teeth ment. Without an organized, detailed treatment plan there is no
would in fact slide easier with a Damon PSL bracket than a traditional direction to a case. However, rather than relying on merely tradi-
elastomeric-based bracket. I decided to perform a tightly controlled, tional cephalometrics to diagnose a case, the practitioner must in-
split mouth study on randomly selected, yet similar bicuspid extrac- corporate a more holistic view of a patient before initiating treat-
tion cases, using The Damon System on one side of the arch and con- ment. Facial aesthetics (fullness vs. flat profile), lip competency,
ventional .018 brackets on the other. The results were indisputably in tongue posture and position, occlusal interferences and tooth
favour of the Damon System, by the fact that the Damon side moved size must be evaluated along with the more traditional aspects of
teeth up to twice as fast as the conventional side. incisor position, interincisal angle and mandibular plane angle.
This is due to two main factors; 1 - reduced friction by the removal of To merely diagnose a case based on NORMS and STANDARDS
an elastic or stainless steel tied ligature, 2 – the increased wire-to-lu- is not what constitutes a Damon diagnosis. Cephalometrics and
men ratio that reduces the binding and friction between the bracket Bolton numbers, while a valuable part of developing a treatment
and the wire. These factors enable more efficient levelling and aligning plan, are not the sole determining factor in treatment planning
during the early stages of treatment and more efficient sliding mechan- cases. For instance, as we will see later, due to the unique con-
ics during the later stages. It must also be noted that even torquing and struction of anchorage in Damon System cases, Class II correc-
rotational tooth movements occur more rapidly when the low friction, tion is viewed from a different perspective than a traditional case.
passive Damon System is utilized. Likewise, deep bite, brachycephalic cases look at the utilization
of disarticulation (i.e. bite turbos) in a different manner. Rather
The low forces delivered by following the Damon System protocol than diagnosing from an extraction vs. non-extraction viewpoint,
allow the Damon archwires, together with the passively ligated brack- a Damon practitioner needs to determine how anchorage will be
ets, to work more in harmony with the patient’s individual biological deployed, how the heavy forces of occlusion are to be overcome,
environment. This has the effect of providing posterior transverse arch how the factor of lip competence will be viewed and even how
development without the use of expanders. Space is created via each blocked out teeth are to be managed (i.e. bypassing vs. tying in)
patient’s individual response to the System. The arch form is not pre- become factors in diagnosing and treatment planning. It is not
determined by an orthodontist or archwire form. As mentioned above, simply a matter of looking at crowding and cephalometrics. Far
space develops as a result of the lateral development, rather than flar- more must be considered in developing a sensible case construc-
ing. The results deliver a full, broad smile, with reduced proclination of tion.
the anterior teeth and stable posterior width changes. As a result, I have
also seen a dramatic reduction in the need for extractions contributing 2. TRADITIONAL VS. ACTIVE VS. PASSIVE LIGATION… Intense
to a positive effect on the patient’s midface. The traditional ravages of debate rages concerning which method of orthodontic ligation is
extractions observed as patients continue to age have been minimized. the most efficient and beneficial mode of delivering orthodontic
The smiles are broader, lip support is greater, the mid-faces are fuller treatment. Panel discussions, journal articles, journal editorials,
and aesthetics are exponentially improved as a younger, more youthful professional meetings and informal get-togethers are all arenas in
appearance is maintained throughout mid-life years. which this hot topic is contested. Not since the days of the legen-
Not every Damon case is to be treated as a non-extraction case, how- dary Case/ Angle debates has an orthodontic philosophy incited
ever. There are a number of instances where extractions are indicated such intense passion. In spite of all discussion, passive self-liga-
and are the preferred treatment of choice. Examples are instances of tion remains the most rapidly adopted technique in the history of
bimaxillary protrusion, weak lip support, tongue thrusts, anterior open the orthodontic profession. (Perhaps this is why the debate is so
bites, high mandibular plane angles and excessively proclined teeth intense). To those who have adopted the Damon System there
in fragile periodontal situations. When, however, extractions will help appears to be little reason to dispute Dwight Damon and his phi-
the profiles or overall dental health of these patients I extract the ap- losophy. A passive self-ligating bracket (PSL) has the least inter-
propriate teeth to render the most favourable result.. Facial aesthetics, face between a bracket and arch wire of any orthodontic delivery
sensible orthodontic diagnoses and fundamental dental health are the system. If the goal of treatment is to allow teeth to slide along
essential determining factors. the archwire (hence the wire is least encumbered by the binding
instigated by the bracket) there can be no question that PSL is the
TWELVE ESSENTIALS FOR MOMEMTUM WITH optimal technique to use. And if the PSL allows the teeth to slide
DAMON TREATMENT along the bracket the easiest, it stands to reason that a PSL needs
Over my past ten year journey through the Damon System it has be- the least amount of force to initiate such movement. If a PSL needs
come apparent to me that there are certain non-negotiable aspects of the least force to move teeth, then the lighter the forces delivered,
delivering prudent, high quality, sensible orthodontic treatment with the more biologically sensible the System is. If the muscles can
the Damon System. These will be outlined below, in chronological control the light forces associated with tooth movement with PSL,
order of implementation. If a practitioner is willing to philosophically anterior tooth position can be and is maintained by the balancing
adopt these components of treatment, it is my firm belief that success of the muscular forces of the lips and tongue. The result is lateral
from a professional and patient perspective, as well as long term sta- arch development and anterior tooth position stability.
bility will be achieved. In a sense, these are the truisms of the Damon Active ligation and conventional brackets, by virtue of the fact
System. Adoption will lead to success….violation will lead to failure. that more binding is introduced, restrict the ability of teeth to slide
1. DIAGNOSIS AND TREATMENT PLANNING… Understanding along the wire when compared to PSL. Current studies underway
that diagnosis and treatment planning is the most essential aspect under the guidance of Dr. Hisham Bidawi substantiate this claim.

4
 Using an OSIM orthodontic simulator, he has shown the binding d). In situations where teeth are blocked out there are two op-
levels to be lower with PSL and the resulting tooth movement to tions. If anterior movement of the anterior teeth is desired,
be less restricted. all teeth are incorporated into the System which allows for
anterior movement (proclination) of the incisors. To the con-
3. TORQUE… An argument postured by active and conventional trary, if anterior position stability is desired and more lateral
ligating theorists revolves around torque. The argument being movement than anterior movement is desired, a coil spring
that a PSL bracket cannot deliver torque due to the fact that one 1- 1 ½ times the size of a bracket is placed and if the tooth
needs to “seat” the wire in the bracket in order to establish torque. is lingually/palatally blocked, the blocked tooth is tied to the
However, torque comes from the incisal and gingival walls of a coiled arch wire with .010 stainless steel ligature. Doing so
bracket, not the base. PSL brackets are NOT frictionless, i.e. there assists the anterior teeth in not flaring forward and encour-
is and must be interface between the wire and the bracket in order ages greater lateral development.
to direct tooth movement. While PSL has interaction between a e). If interference between brackets and opposing teeth are cre-
wire and bracket, the amount of binding and friction between ated during initial construction, bite turbos (Pearl # 6) are
wire and bracket is less than with conventional and active bracket employed.
systems. Therefore, in order to facilitate movement along the arch f). If “colored ties” are requested by the patient, they are placed
wire and to develop more “play” in the system, the largest wire in under the wire and over the bracket. They serve no purpose
the Damon System is a .019 X .025 Stainless steel wire. other than decoration.
The Damon System is founded on the principle of “Variable Tor- g). Severely rotated teeth can be “de-rotated” by placing elastic
ques”. Multiple torques are available for many teeth. Maxillary chain under the wire and tied in the appropriate direction. If
incisors have three specific torques, i.e. (High, Standard and Low). difficulty is encountered in closing the slide on the brackets
Mandibular incisors and all canines have two torques (Standard due to rotation, it is advisable to close the slide before plac-
and one variation). Premolars have only one torque per tooth. ing the arch wire, i.e. convert the bracket into a tube.
High torque maxillary brackets are generally used in Class II cas- h).***A word of caution…light forces are best. When in doubt,
es, extraction cases and those instances where additional angula- use the lighter wire available and place niti coils where teeth
tion is desired. Low torque brackets are used in maxillary and are blocked. Larger wires, engaged in all teeth, can provide
mandibular incisors where there is a desire to combat flaring from undesirable flaring of anterior teeth.
either a situation of severe crowding or mechanics which would
tend to cause flaring (i.e. Class II elastics on lower incisors). 5. WIRE PROGRESSION… To adequately begin a discussion on
Future generations of Damon brackets will likely incorporate even wire progression one must first realize the treatment stages of the
more variations for torque. As more and more cases are treated it Damon System as they relate to the phases of treatment. The four
is apparent that other options will be of distinct advantage phases of Damon treatment are 1) round CuNiTi, 2) rectangular
CuNiTi, 3) Major mechanics (posted wire phase) and 4) Finishing.
4. INITIAL APPOINTMENT… Understanding how to commence Treatment stages are 1) Dento-alveolar development, that is, the
Damon treatment can not be emphasized enough. Great care and initial arch form development, rotation and alignment 2) Torque
understanding must be employed when starting a case with the Control and Levelling, that is, the implementation of rectangular
Damon System. The following components are essential. wires to continue arch form development, root inclination, con-
a). All teeth must be incorporated in the system, that is, the con- tinued bite opening and space control, and 3) Completion of the
struction must extend from second molar to second molar first two treatment stages coupled with finishing and detailing.
in the maxilla and mandible. Forces need to be distributed Both the treatment stages and the treatment phases correlate with
throughout the entire mouth, not focussed on certain teeth. actual treatment milestones, i.e. certain procedures which are
Bonding procedure, i.e. direct vs. indirect, are personal de- performed at prescribed junctures of treatment. These are the ini-
cisions made by each doctor as is bracket position, bracket tial bonding appointment, the repositioning appointment (when
placement and method of construction. a panorex is taken and bonds are repositioned in response to the
b). All cases must start with an arch wire NO LARGER than .014 positions noted on the panorex), arch coordination appointment
CuNiTi. The wire should be left in place for no less than 10 (wax bite) and the band removal (debond) appointment.
weeks before proceeding to a larger diameter. Typical wire
sizes are .013 (10-15% of cases started) and .014 (85-90% of To summarize the phases of treatment and the treatment that takes
cases started) CuNiTi. place in each phase, the following is outlined:
c). Binding and friction are extremely low with PSL brackets.
So, if care is not taken to secure the wires and prevent their Phase I – Levelling and aligning
lateral movement, numerous emergency appointments will Arch development is initiated by the use of .014 Damon Copper NiTi
be needed to address asymmetrical wire movement. Crim- or .013 Damon Copper NiTi if severe rotations or periodontal issues
pable stops need to be placed on all CuNiTi wires to prevent are present. The aim of this phase is to resolve 90% of the rotations,
the wires from sliding from side to side. In the maxillary which should be accomplished in 10-20 weeks. As I routinely have 10
arch a stop is placed 1 mm from the mesial and distal sides weeks between appointments during this stage, this equates to 1 or 2
of the bracket of the tooth which is most anterior from the visits. It is essential that archwire stops are used to prevent wire slid-
crowding and needs the least movement. In the lower arch ing distally from the buccal tubes. Always place these stops anterior
a single stop is placed as close to the midline as possible, to crowding.
anterior to the crowding, between the two teeth which are Phase II – High tech edgewise
in the best position. Leveling and aligning is completed and all remaining rotations are re-

5
solved. Torque control is initiated together with anterior space consoli- occur with posterior bite turbos, so they should only be utilized
dation. Arch development is still progressing. in instances where bite opening in not desired. Transverse lateral
The wires generally utilized are .014 X .025 then .018 X .025 Damon development (i.e. crossbite) correction is also facilitated by dis-
Copper NiTi. In a deep bite division 2 case, a .017 X .025 or .019 X articulation. By removing the occlusal forces on posterior teeth,
.025 Damon reverse curve NiTi is also a good option. greater freedom for lateral expression is achieved and ensuing
A panorex is very often taken so I can see if any brackets need to be transverse correction can be more readily attained.
repositioned. The duration of this phase is usually from 10-20 weeks,
but now I have 8 weeks in between appointments.
Only move onto the next phase when a stainless steel wire can be 7. EARLY TREATMENT… The light force delivery of the Damon Sys-
inserted passively. tem lends itself well to those cases where early intervention and
treatment is indicated. The goal of early treatment has historically
Phase III – Major mechanics and finishing been to correct a developing malocclusion and create an environ-
Torque control is completed and all posterior space is consolidated by ment where favourable growth and development will occur which,
using tie-backs which also prevent posterior space from re-opening. in turn, minimizes the amount of treatment which will need to be
This is the time to fully coordinate the upper and lower archforms by performed at a later time. Severe crowding and severe skeletal ab-
copying the lower archform already present and making the upper arch- normalities have been the primary facets addressed. This remains
wire 1-2mm larger all around the arch. If slightly more arch width is among the focus of early treatment with the Damon System. How-
required, for example in some cross-bite cases, then the archwire may ever, understanding light force orthodontics has enlightened many
be expanded slightly at this point. Our testing has shown that by using practitioners to include in early treatment diagnoses those cases
this technique, the forces are still kept to a very low level. The duration where creating space prior to eruption of permanent teeth (particu-
of this phase is anything from 20-40 weeks with 6 week appointment larly canines) allows the permanent teeth to erupt into keratinized
intervals for the major mechanics and 4 week intervals for the finishing. tissue, resulting in more favourable periodontal health. The Damon
This enables maximum time management in your practice and maxi- Space Gaining Appliance (D-Gainer) is the mechanotherapy uti-
mum treatment of patients in the shortest duration possible. lized to create space for erupting teeth with the intent that teeth will
not need to be extracted AND they will erupt into keratinized tissue
Phase IV – Finishing for improved periodontal health. A variation of the traditional “2
Finishing is a personal decision for each practitioner. I generally use X 4” appliance, its distinct advantage over previous designs is the
TMA wires to finish my cases, along with specific elastic patterns to aid fact that the use of PSL brackets allows the anterior teeth to remain
and assist final positioning of the teeth. Great concentration is given in a more upright position and the space necessary for eruption
to gingival margins as they should be equal in height signifying proper of the permanent teeth comes primarily from the lateral develop-
tooth-to-tooth relationships as well as ideal buccal-lingual root posi- ment typically seen with the Damon System. Low torque brackets
tioning. are used in its construction (to minimize flaring) and medium Niti
coil springs are used between the lateral incisors and first molars.
Utilization and incorporation of .018 X .025 CuNiTi in wire sequenc- The coil spring is activated 1 – 1 ½ brackets larger than the neces-
ing is worth noting. It appears that this wire is a threshold wire. Wires sary space. Patients are evaluated every 8 weeks and the NiTi coil
smaller than this is size and dimension appear to allow the “patient spring is re-activated at these appointments until the desired result
specific biological response” to occur. Once .018 X .025 is inserted it is achieved. The vast majority of these cases do not require extrac-
begins to “drive” the archform in that once left in place for more than tion of permanent teeth and enjoy an excellent periodontal status.
six weeks, the individuality of the arch is no longer driven by the bio-
logical response of the patient. All arches begin to have the same form In cases of developing Class II skeletal relationships a “Telescoping”
in that the .018 X .025 CuNiTi has overpowered the biology and re- Herbst appliance is constructed with stainless steel crowns on all four
placed it with the generic Damon arch form. BE SURE TO NOT LEAVE permanent first molars to support the appliance. Typical age for initia-
.018 X .025 CuNiTi WIRES IN FOR LONGER THAN SIX WEEKS. tion of Herbst therapy is 10.5 years for females and 11.5 years for male
patients. The Herbst is typically worn for 15-18 months at which time
6. THE THEORY OF DISARTICULATION… The forces of occlusion it is removed and the patient segues into full fixed treatment. Buccal
will overpower what the light forces of the CuNiTi wires in the tubes can be soldered onto the molar crowns allowing the practitioner
Damon System can deliver. Progress will be minimal if occlusal to simultaneously construct a D-Gainer along with the Herbst. By doing
forces limit the ability of the wires to express themselves. As a re- so the options for treatment are increased from simple Class I crowded
sult, it is imperative that disarticulation be instituted in the Damon cases (D-Gainer alone) through to severe Class II, Division 2, cases with
System in order to maximize the biological response to the light severe crowding (D-Gainer with Herbst). As with a D-Gainer,
Damon forces. Anterior bite turbos appear to be the best method the Herbst is advanced every 8-12 weeks until an edge-to-edge rela-
for disarticulation. By placing them on the lingual surfaces of the tionship is achieved, at which time the edge-to-edge relationship is
maxillary incisors they allow for posterior disarticulation. The maintained for a 3-6 month period followed by the Herbst’s removal.
posterior disarticulation allows for unencumbered lateral devel-
opment, light force space closure, more efficient alignment, more 8. SPACE MECHANICS…Interesting to note is that the same metal-
efficient levelling and faster treatment times without needing to lic mechanotherapy, NiTi coils, are used for both space opening
apply heavy forces. In cases of anterior open bites and extreme and space closure. Medium NiTi coils are used for their ability to
overjet which preclude contact of an anterior bite turbos, pos- deliver a consistent force throughout the duration of need, when
terior bite turbos, placed on the buccal cusps of the mandibular lack of (crowded non-extraction cases) or excessive (spacing or
second molars will suffice. Be aware that bite opening will not extraction cases) space is treated.

6
 a. Crowded cases…as already mentioned, when teeth are should be closed, the patient should have steel posted wires in place
blocked out, medium open coil springs are placed in the and the case is ready to be finished.
area where space is desired. The amount of coil used is equal
to the space present PLUS 1 – 1 ½ a brackets width. The 9. ELASTICS…The purpose of elastics in the Damon System is to guide
arch wire can be as thin as a .014 round CuNiTi wire if the the teeth into the desired positions, without the cumbersome as-
NiTi coil is light. Little deformation or distortion of the wire pect of binding generally associated with traditional orthodontic
is demonstrated providing the coil is kept light. If more coil is therapy. The main elastic utilized is a 5/16...6 ounce...elastic.
used, space does not open any faster and the clinician runs These are generally used in the third phase (major mechanics) for
the risk of flaring the anterior teeth due to excessive lip or Class II and Class III corrections. NOTE: The arch wire is cut distal
cheek pressure exerted on the coil and the tendency for the to the lower first molar for Class II correction and distal to the up-
initial light CuNiTi wire to be adversely influenced by the per third molar in Class III correction in order to allow the sliding
coil and muscular pressure. When a tooth is blocked lin- mechanics as outlined in the anchorage section to occur. Cross
gually or palatally, the blocked tooth has a buuton, eyelet or bite elastics generally are 3/16...4 ounce...elastics. Vertical clos-
mini-tube bonded to it and then the attachment is tied to the ing (finishing) elastics are generally the 5/16…6 ounce…variety.
coil on the arch wire with a .010 steel ligature wire. Succes- Recently, great attention has been given to “early” elastics. That is,
sive visits will require reactivation or re-insertion of new coil starting elastic wear in the initial wires in situations where a major
keeping it at the 1 – 1 ½ brackets specification. The blocked Class II or III correction, open bite or transverse correction is de-
tooth may not have enough space available in order to suc- sired. Generally, for Class II correction a 2 ounce elastic, from the
cessfully bond a Damon bracket. Likewise, in those instances upper first premolar to the lower molar is used in the light round
a ½ Siamese bracket, an eyelet, a hook or button is bonded arch wires. As the case progresses to rectangular wires a 4 ounce
to the tooth and the steel ligature is tied accordingly. Once elastic is employed from the upper canine to the lower first molar
sufficient space is gained, the attachment is removed and a and, finally, in the posted steel wire phase a 6 ounce elastic is
normal Damon bracket is placed on the tooth. used as outlined above from the post on the maxillary arch wire
b. Spaced cases… Traditional elastic chain, placed under the to the lower first molar. Impressive corrections of severe maloc-
arch wire, from canine to canine, is used to consolidate clusions have been and are being achieved via the use of early
spaces on an arch wire no smaller than a .016 X .025 CuNiTi elastics. As 2009 progresses it is my belief that more uses of early
wire. Space is gathered distal to the canine and mesial to elastics will be displayed and employed.
the first bicuspid in either extraction or spaced cases. Once
the space is localized in that area, a .010 steel ligature wire 10 ANCHORAGE…Effective and efficient anchorage is the goal of
is used to ligate canine to canine together in order to keep successful orthodontic treatment. In order to develop and main-
the anterior spaces closed. This anterior ligation will remain tain the proper occlusion anchorage is essential in maintaining
in place, under the arch wire, for the remainder of treatment tooth positions in some situations (maximum anchorage) and al-
as the case proceeds to a posted wire, typically .019 X .025 lowing them to move (minimum anchorage) in others. PSL clearly
posted steel in the upper and .016 X .025 posted steel in the shows benefits when anchorage demands are indicated.
lower. A posted wire is that wire where a crimped or sol- Traditional orthodontics has resorted to many modalities in efforts
dered posted is added to the steel wire in the interproximal to establish anchorage. Extra-oral devices, such as headgears,
area between the lateral incisor and the canine. Typically, have been commonly used for years. Intra-oral appliances, such
a 9 mm Medium NiTi coil spring with an aperture on each as transpalatal arches, lingual arches, Nance holding arches and
end is added to the arch wire, extending from the crimped or similar designs have been used, but are contraindicated in the
soldered post to either the arch wire as it extends out of the Damon System as their “transpalatal” aspects limits the desired
tube (in minimum anchorage situations where the arch wire lateral development so essential to successful Damon therapy.
is cut distal to the first molar) or on the buccal hook of the Quite simply, an arch can not develop laterally when a transpala-
first molar (in maximum anchorage situations where the arch tal arch is maintaining that dimension, much as a fixed lingual
wire extends through the second molar and the first and sec- arch maintains the width in the mandibular arch.
ond molar are ligated together for increased anchorage). The Recent advances in anchorage have been shown in terms of the
NiTi coil should close the space at a rate of 2 mm/ 6 week presentation of Temporary Anchorage Devices (TAD’s).
interval. If space does not close at that rate, a stainless steel These can be used successfully with the Damon System due to
Pletcher coil is added to the system in the same configuration their non restrictive aspect of lateral dimension. Placing a TAD in
as the Niti coils are used. A Pletcher coil, being of steel with a recipient site allows for anchorage without limiting the lateral
stronger forces, will generally close the space faster. It is only development of the cases. They have been shown to be very effec-
activated 3-4 mm, however, and this minimal adjustment re- tive in tooth translation, but are particularly indicated in vertical
quires more frequent appointment intervals for the purpose of correction, most notably intrusion of teeth. They are, and should
continual activation. be, part of a contemporary orthodontist’s armamentarium.
Once space is closed the arch is secured via molar to molar ligature The Damon System capitalizes on the lack of binding when es-
with .010 steel ligature ties or with elastomeric “tie-back” modules. tablishing anchorage. The second molars become the key to its
The tie-backs are placed from the post on the wire to the buccal hook establishment. As previously discussed incorporating second mo-
on the first molars. The purpose of the tie-backs is to keep the spaces lars into the appliance allows not only for adequate dissipation of
closed. Keep in mind that a steel ligature wire, placed from canine forces throughout the dental arches, it also allows for increased
to canine, under the arch wire, following consolidation, is kept in anchorage when needed. With so little binding evidenced in
place until the case ids completed. At this point in treatment all spaces PSL the teeth slide along the arch wire more freely than previ-

7
 ously seen, and, as a result, the “strain” of anchorage is lessened. lion cases have been treated and the vast majority of situations
Hence, merely by incorporating second molars in the appliance have delivered extremely positive results. The key is to maintain
will allow for increased (maximum) anchorage. Conversely, elim- the good results and to maintain the stability as the years following
inating second molars from the appliance (cutting the arch wire active treatment progress. We want our cases to be as “effective”
distal to the first molar) reduces the anchorage of the System and in 20 years as they are now. We want our patients to be as happy
allows the posterior teeth to slide forward far easier (minimum). (affected) with their results in 20 years as they are now. We as
Class II correction can be achieved by incorporating the second professionals want the pride a well-treated, stable case gives us.
molars in the upper appliance, and by cutting the arch wire distal Retention protocol is quite routine. A fixed bonded retainer is
to the lower first molar. Upper anteriors are retracted and lower placed lingually on the upper four incisors and on the lower six
posteriors are protracted. Situations for Class III correction, profile (canine to canine) teeth. Bond-A-Braid (.016 X .022) is used as
needs and congenitally missing teeth space closure can all be ad- the retention wire. In addition to the fixed retainers a removable
dressed by manipulating the anchorage of the case. night time retainer is given as well. In most cases, a simple vac-
So, anchorage has always been a great concern with conventional uum-formed “Essix”-type retainer is used. In more severe maloc-
appliances, but when the Damon System and its protocol are fol- clusions, (i.e. severe Class II or Class III, open bite and crossbite
lowed, this is not as great of an issue to consider. The anchorage cases) a Damon Splint is utilized. This consists of two invisible
demands of the Damon System are far lower than conventional retainers affixed together with hard acrylic so that it is worn as an
systems due to the considerably reduced friction offered by the athletic mouthguard might be worn, at night. In Class II cases the
passive lumen all Damon brackets possess. I have virtually aban- construction bite is made with the teeth in an edge-to-edge rela-
doned the use of transpalatal arches and Nance holding arches tionship to encourage forward posturing of the mandible, much
within my practice. the same as a functional appliance would. For Class III, open bite
and transverse situations, the wax bite is constructed in the centric
11. FINISHING… BOTH ORTHODONTICALLY AND COSMETICAL- relation position. Damon splints are fabricated with the intention
LY…As mentioned above, finishing is a personal decision for each that they will be worn at night, indefinitely.
operator. What one doctor believes constitutes a finished case may It has been most gratifying to follow my cases throughout the past
differ dramatically from another. For simplicity I suggest that a eight years. The stability, periodontal health and, most important-
panorex be taken at the end of the rectangular CuNiTi wire phase ly, the aesthetic results have been more than gratifying. We have
in order to evaluate root parallelism and reposition those brackets successfully affected a smile which continually has the effect we
which are not adequately positioned. In my opinion, however, desire, that is, a content, confident, attractive and healthy indi-
more attention should be given to buccal-lingual root position. It vidual.
appears that a great number of relapsed cases relapse because the
apex of lingually/palatally blocked teeth are not brought forward
significantly. If the apex is left lingual, once retention is ceased,
the tooth will begin to upright to the original position of the apex.
If the apex has been left in an adversely lingual location, the tooth
will upright lingually and relapse crowding will ensue. Without
the advantage of a cone beam/CAT scan a basic clinical observa-
tion of the gingival margins should give the operator an indica-
tion as to whether the root has been brought buccally enough.
If excess tissue is apparent on a particular tooth the chances for
relapse is great. I encourage all practitioners to be adept at adding
positive root torque (i.e. negative crown torque), particularly on
anterior teeth, to be able to upright the teeth and align gingival
margins. TMA is a wonderful wire to use as a finishing wire as it
allows gentle torque to be placed in the wire for root torque and
also small in-out/ incisal-gingival steps can be placed.
Tooth recontouring is also of great benefit in aesthetic finishing.
Adult cases can particularly benefit from re-contouring in an at-
tempt to establish a more “polished” finished case by removing
asymmetric wear patterns on teeth and level out incisal edges.
Gingival recontouring with the aid of a laser is also of benefit in
delivering an aesthetically finished case. A finished case ideally
has even gingival margins and well contoured and shaped teeth.

12. RETENTION AND STABILITY…A case is only as successful as its

stability. I strive to deliver the “WOW” case. To me a case should
not only be effective (i.e. good occlusion)… it must be affective
(deliver a response to the owner of the smile and everyone who
sees it. It affects the way someone is perceived or thinks about
themselves. They are affected by the smile!) as well. The Damon
System has been in existence for more than ten years. Over 2 mil-