To understand how the IP Appliance program works, this summary should help you understand why things happen when you answer the questions. Rotations features in the IP brackets are indicated when you click mesial or distal in the diagram (question 1). That is not difficult for users to understand. But why the incisor torque is designed, well that is more difficult.
Upper root torque:
Added incisor Lingual Root torque:
Upper incisor is retroclined (upper 1SN 99 or less)
Check “retracting upper incisors” in question 2. This compensates for the expected detorquing resulting from negative archwire spin in the bracket slot, previously experienced with the Roth prescription.
If an upper lateral incisor is blocked out to the lingual, you would usually use a bracket with added labial root torque, BUT, if you are also retracting the upper incisors a long way (defined by 3mm or more retraction, then the roots of the upper incisors are brought back to those of the lateral incisors. The program then gives you all lingual root torque (Li) upper 2-2. This is a “priority” in the programming.
This is the default torque for the incisors
Added upper incisor Labial root torque:
Upper 1SN is 115 degrees or greater and not closing space
If class III and wits less than –4
If the tooth is blocked out to the lingual
For cases that you wish to prevent incisor advancement upper and lower with La/La torque, you can check “blocked out to lingual” in question 5 for upper 2-2 to create labial root torque, or custom select each bracket. For lower Labial torque, select “prevent lower incisor advancement” in question 2.
Added upper cuspid lingual root torque
Cuspid Torque in question 5
Ceramic is NOT yet available with added lingual root torque on the upper cuspids, so this changes to Roth torque when ceramic is indicated.
Added cuspid labial root torque
Cuspid torque in question 5: Mostly used for cuspids in a “palatal” impacted position to start or in previously treated non-extraction with flaring from the expanded archwire.
Question 2, maintain the lower incisor in a forward position. Used in minimum anchorage cases to engage the lingual cortical plate, creating cortical anchorage and the ability to maintain lower incisor position. This is needed in most upper 4, lower 5 extraction class II cases. Can be used in any case where you wish to maintain (or advance) the lower incisor crowns. Ceramic brackets are available in this torque, and are positioned with the “notch” between the tie wings in the gingival position.
Added incisor labial root torque
Class III cases with a wits less than –4
A tooth blocked out to the lingual
Limit the lower incisor advancement in question 2. This is a very valuable use of this bracket, as incisor advancement is the cause of many an extraction diagnosis. Labial root torque can also be used for added lower arch anchorage in class II cases, enabling the use of class II elastics or to control torque in upper 4 extraction cases
Ceramic brackets are available in this torque, and are positioned with the “notch” between the tie wings in the incisal position.
Added cuspid lingual root torque
Cuspid torque in question 5
Added lower cuspid labial root torque
Lower arch is expanded by the archwire (question 7). This feature combined with rectangular wire alignment can improve your retention experience (intercanine width collapse) by preventing the tipping of the cuspid over the crest of the cortical bone.
Thin lower 3-3 brackets
When deep bite is greater than 80%
When deep bite is average or deep (80% or less) and you are retracting the upper incisors.
Molar Buccal Tubes and custom welds
I will not explain the addition of headgear tubes, Goshgarian TPA sheaths, Triple tubes for piggyback wires, or Lip bumpers. These are obvious selections in question 4.
Since we are custom welding for each patient, the IP Appliance offers welding of the buccal tubes onto a band at an angle. This can be confusing, as the nomenclature indicates which way the crown would tip if a straight archwire were engaged.
Goshgarian Transpalatal Arch (TPA) sheath (sh)
indicated Goshgarian sheath on the tooth
Skeletal open (ceph summary) and closing upper bicuspid space
Distal tube on the upper 6s (16D)
If class III and wits of –4 or less. This tube does not have the Roth “distal offset”, which is really “mesial rotation” in our nomenclature. Simply, the 16D leaves the mesial-palatal rotation of the upper molar, consuming archlength, helping the advancement of the upper incisors. This may also be helpful in consuming excess upper space in the upper 4 only extraction diagnosis.
Upper Mesial Tip welds (crown tips mesial, root tips distal)
When you are distalizing the tooth
Restorative replacement of upper 4s when you are banding the 5. To keep the adjacent roots parallel to all implant placement.
Upper Distal Tip welds (crown tips distal, root tips mesial)
If you are closing upper 5 extraction space, tip weld on the 6 bands. Especially helpful if you have a low maxillary sinus.
If you are closing upper 6 extraction space on 7 bands
If you are closing upper 7 extraction space on 8 bands
Restorative replacement to keep the roots away from the space. For example on upper 5 bands when the 6s are being restored.
Lower Mesial Tip welds (crown tips mesial, root tips distal)
Not seen on the lower molars, but is automatically incorporated into the class II elastic (CIIE) and uprighting (UP) band welds. The CIIE variation is used for closing lower 5 extraction spaces, the UP variation for closing lower 6 extraction spaces.
On lower 5s when closing lower 4 extraction space for root parallelism.
Lower 5s when a band is used and restorative replacement of the lower 6. Keeps the root parallelism.
Class II Elastic (CIIE) (rotates the crown mesial-buccal, same Roth torque, leaving the crown tipped slightly to the lingual, 3 tip weld).
Retract the cuspid more than 3mm by the use of class II elastics in question 4. The design compensates for the unwanted tipping by having a custom tip weld (distal crown tip), and preventing mesial-lingual rotation into the lingual cortical plate by having added mesial rotation (as compared to the Roth prescription).
Closing lower 5 extraction space (for root parallelism and control of the unwanted mesial-lingual rotation) if on 6 bands
Lower lingual arch indicated on the first molars will “cancel” this prescription, giving you a standard Roth (R) instead. This is to prevent the over-expansion of the lower 7s if the first molar is not allowed to rotate because of the LLA.
In question 4, you may also select this buccal tube on the lower 7s, where class II elastics are expected to be placed on these teeth (possibly double elastics to lower 6s and lower 7s to move the lower arch forward).
Uprighting (Up) (rotates the crown mesial-buccal, uprights the crown to the buccal with added torque)
Molar uprighting. This is welded to tip the crown distal (5 tip weld).
This bracket is especially good to use when closing lower 6 space
Cancelled if LLA on the 6s to prevent over-expansion of the 7s
Added Lingual root torque to the lower 7s
Posterior tooth is tipped to the lingual. This is the answer for those difficult situations of uprighting a lingual tipped lower 7 crown.
Partial erupted (pe)
Partial erupted is indicated in question 3. This lower 7 bonded bracket is placed ONLY on the mesial cusp, not in the middle of the tooth. It can also be applied to lower 8s or upper 7s/8s.
Short clinical crowns:
When the upper bicuspids are checked, the bonding pad is changed from the offset pad to the standard sized pad.
When lower bicuspids are checked, these teeth receive a band (2) since these cases typically have very tight muscles of mastication. Bonding with a smaller pad invites frequent bond failure.
How to use the IP Appliance Tab
The appliance design step follows the case diagnosis, and should be completed before the second consultation, so the teeth to be banded have been already chosen. Separators are then placed following the second consultation for the indicated teeth. The band sizes, generated from the band fitting appointment, are added to the appliance design before the order is placed.
The default is standard Roth, bonded appliance, missing 8s, and the standard positioning setup. In this case, the cephalometric measurements indicated the need for upper incisor brackets with added lingual root torque, done before the appliance design.
The default, or starting appliance will be an all bonded, standard Roth (R) appliance from 7-7 upper and lower. The 8s are checked as missing. You may see some brackets already with a variation. These changes came from the cephalometric tracing or classification section of your software. The most common change will be the addition of lingual root torque brackets on the upper incisors for cases with retroclined upper incisors.
The default height placement is the standard setup, but this may have already changed from your indications of deep bite 50%, 81% or greater, or open bite in the classification section.
A (*) has been added to all fields that influence the appliance description. Be certain that these have all be completed before starting the IP appliance design window. There are some numbers in the ceph tracing that also influence the prescription, so be certain to either trace a ceph and import the numbers OR manually input the numbers from a hand traced ceph.
Step 1: Indicate Missing Teeth, Teeth to be Extracted, and Rotated Teeth
Using the tooth diagram on the top-middle of the screen, right click on a tooth, and indicate if the tooth is missing, to be extracted, rotated. Left click on the correct answer. If you make a mistake, right click again and left click on the correct answer. The new indication will erase the first answer and replace with the new one. You also have option to clear the answers to make the blank.
If you are uncertain of the international numbering system (quadrants UR=1, UL=2, LL=3, LR=4 and teeth 1-8 added to the quadrant), then you can click on any tooth in the diagram and the number will be listed above-center.
A right click on tooth 13 results in a drop down window with options to select.
In mixed dentition cases, you can indicate “primary” and a bracket will not be ordered. If you wish to receive a bracket for the unerupted tooth, then do not indicate primary. Any tooth that is clean (no M, D, X, P on the diagram), will receive a standard Roth bonded bracket.
On second molars that are not yet erupted, you may want to indicate missing if you do not wish a bracket to be ordered. Unused brackets can be filed into your practice inventory, and brackets you forget to order can be taken from your repair inventory, so do not stress.
Step 2: Treatment Design
Answer the questions on the lower left corner, left clicking on the open square for any yes answers. Many of the questions will then expand for you to indicate which teeth are affected. If a tooth is not listed, then there is not a bracket variation available or the programming is not designed for the missing function.
When selecting the second step, indicate the treatments that you are planning for the individual case. After the first indication, you will be asked to indicate which teeth you plan to upright or which spaces you plan to close. Grayed boxes mean the tooth missing or the space does not exist in the tooth diagram.
Retracting Upper Incisors 3mm or more: This will add lingual root torque (Li) to the upper incisors.
Molar Uprighting: This will change the brackets on the indicated teeth to the “uprighting” bracket (Up), which has added compensations of mesial rotation, crown tipback, and lingual root torque (buccal crown torque).
Closing Space: be certain to indicate that you are closing extraction spaces or the spaces of any missing teeth. When closing 4 space in skeletal open bite cases, TPA sheaths (sh) will be added to the upper 6 bands. When closing 5 or 6 spaces, you will see tipping added to the molars and bicuspids for root parallelism (M-G is placing the slot mesial-gingival, D-G is placing the slot distal-gingival)
Distalization: this would be indicated in any upper 7 extraction cases or non-extraction distalization cases to correct class II. Mesial crown tip (distal root tip) will be added to the band as a custom weld or an indication of distal-gingival (D-G) for bonded bracket placement.
Restorative Replacement: indicate any teeth you plan to place a fixed bridge or implant to replace a missing tooth in the final occlusion. The roots of the adjacent teeth will then be tipped to be more upright for the abutment preparation.
Advance the lower arch (with lower labial corticotomy): To reduce tipping of the lower incisors during an intentional incisor advancement, brackets with added labial root torque (La, same as lingual crown torque) is added to the lower incisors.
Non-Extraction, limit lower incisor advancement: If the lower arch is treated non-extraction and you do NOT wish the lower incisors to advance, then click this question “yes” and added labial root torque (La, same as lingual crown torque) is added to the lower incisors.
Step 3: Which Teeth to Band:
You have the choice of right clicking on the tooth diagram and indicating “banded” or checking the box on the lower left of your screen to expand the possible teeth, clicking on any that you wish to band. A silver line will cover any teeth you indicate on the tooth diagram. When you indicate a tooth needs a band, a “?” sign will show up in the master prescription list on the right side for the band size. In the numbering code, “2” after the first letters (R, M, D) indicates a band, no number 2 a bonded bracket.
Bands are selected in the third step by indicating the teeth, or right clicking on the tooth to be banded. Cleats, partial erupted brackets (lower 7s) and ceramic brackets are also indicated in this appliance design step.
The default is for NO lingual cleats. You have the option of placing cleats on all bands or selecting which teeth you wish to receive lingual cleats. The big problem is when you do not have a lingual cleat available and you want to use lingual mechanics. The IP system has definitely reduced the need for lingual mechanics with the added bracket compensations, so do not expect to need as many cleats.
Partially Erupted: lower second molars ONLY that are partial erupted can receive a small bracket (pe) that is bonded to the mesial cusp of lower molars.
Ceramic Brackets: if you wish to use ceramic brackets, the IP system has 5-5 upper and lower available. Rotation wedges from your inventory create the rotation variations in the bracket specially designed for that purpose. If lower ceramic is chosen, you will see a warning message appear under the tooth diagram about upper incisal edge wear with lower porcelain brackets. The “clear” button will erase the warning at any time.
Step 4: Additional Options:
Indicate any of the appliances that you wish to use to receive the appropriate attachment on your band.
Cervical or high pull headgear: adds headgear tubes (hg) to the indicated upper molar bands.
Lip Bumper: adds lip bumper tubes to 36 and 46 bands. Lip bumper tubes may also be used in orthognathic surgery cases for intermaxillary fixation
Lower Lingual Arch: clicking this makes a LLA notation on the indicated teeth in the notes section of the master prescription list. Welded lingual arch sheaths are NOT available in the IP system.
Class II elastics 3mm+ cuspid retraction: if you have more than 3mm of cuspid class II (half a tooth or more class II), and you plan to use class II elastics to make this correction, then click yes. The 36 and 46 (lower first molars) will receive brackets with additional mesial rotation compensation, and distal crown tip custom weld. If a bonded bracket is used, then a positioning variation of “mesial-gingival” (M-G) is indicated so you will place the mesial bracket slot more gingival. The code for this bracket variation with added compensation is “CIIE” for class II elastic.
Goshgarian TPA: 036x072 lingual sheaths (sh) will be added to the indicated upper molars. If only one side is indicated, you will receive a warning on final appliance check that the other side should also have a sheath. Clicking “auto correct” will make a band for the teeth that you wish to have a sheath attached.
Piggyback archwires: To be placed on bands only, there are triple tubes on the upper molars (pig) which have 2 archwire tubes and a headgear tube. On the lower molars, double archwire tubes allows for a double archwire to be used in that arch.
Open coil (stainless steel): Rotations are caused by the pushing and pulling of coil springs on brackets. The most severe is when a space is re-opened between bicuspids. Stainless steel coils generate the most force and therefore are the main cause of these tooth rotations. You are welcome to indicate any teeth that nickel-titanium coils will be applying the force if you feel that such force will create a rotation. If the bracket does not already have a rotation bracket to compensate for this unwanted tooth movement, the addition will be made.
Indicate the side of the bracket where the force will be applied and the appropriate rotation calculation will be made by the program.
Step 5: Malocclusion Characteristics
Short clinical crowns: The upper bicuspids commonly have short clinical crowns that the standard offset bracket pad will not fit. By indicating short clinical crowns, you will receive a small bracket pad (s) on the indicated upper bicuspids. You may want to consider changing these teeth to bands, especially in closed bite cases.
Blocked out to lingual: Incisor teeth that are blocked out to the lingual will receive added Labial root torque (La), UNLESS there is already the need for lingual root torque for retraction of incisors. These brackets will help to overcorrect the root torque for improved retention.
Posterior teeth tipped lingual: By indicating a lower posterior tooth as inclined lingual, a band with a lingual cleat will be added to that tooth so that posterior cross elastics can be applied to the cleat to help upright the offending tooth.
Maxilla severely tapered (sagittal plane): Added lingual root torque (Li) is applied to the 13,23 in the master prescription. In some cases, the maxilla is severely tapered near the root tips. The standard Roth prescription on the upper 3s forces the roots into the buccal cortical plate, causing root prominence and/or resistance to retraction. Some also would like to retract cuspids on rectangular archwires, making added lingual root torque a treatment advantage.
Vertical palate with thin alveolus: Common to bimaxillary protrusive cases is a very thin alveolus that resists upper incisor retraction. Additional lingual root torque is added to the upper incisors by checking this feature.
Severe bicuspid rotation (>60 degrees): by indicating a bicuspid is severely rotated, a band with a lingual cleat is added to the individual patient prescription to allow the use of lingual (chain) mechanics to help derotate the tooth.
Step 6: Anterior Esthetic Arrangement
Click on one of the 4 possible tooth arrangements for the upper anterior teeth. Standard gives the typical “denture setup” of the central incisors on the occlusal plane, upper lateral incisors 0.5mm above the plane and the cuspids 0.5mm below the occlusal plane. “Level” places the incisal edges and cusp tips on the occlusal plane. “Canine minus” gives the standard incisor setup with the cuspid on the occlusal plane. “Canine plus” puts the incisors on one plane and the cuspids below the plane.
If the patient has an opinion, then please decide this from the beginning of the case to reduce wire bending. Otherwise, the doctor will choose the esthetic arrangement. Leave the chosen picture “on” and the heights of the upper 3-3 brackets will reflect this arrangement within the standard/deep bite/open bite setups. It is important to smooth the edges of all the anterior teeth prior to bonding the brackets to obtain this accurate tooth arrangement. Be certain to hold the bracket placement instrument parallel to the occlusal plane to obtain the proper bracket height.
Step 7: Type of Archform
The results of your archform selection should be indicated. The only appliance change is for the lower expanded archform, with added labial root torque (La) to the lower cuspids to prevent tipping around the crest of the cortical bone during the expansion process. Retention should be improved by reducing this lateral tipping. Alignment on a rectangular archwire (018x025N heat) is recommended to allow the added torque during the alignment stage.
The doctor MUST always check the bracket prescription before the order is sent. Review the bracket prescription and codes, confirming that this is the desired prescription and the classifications have been made correctly. If you need a description of a certain bracket code, then left click on that bracket and a description will appear under the tooth diagram.
Left click on the bracket to drop down and select ANY available bracket or band variation for that tooth. If the variation is not listed, it is not available (yet) in the IP Appliance system.
When selecting custom bracket variations, the computer will give you a description of the bracket, including the clinical situation where the variation is used. You may then click on the down arrow and a list of all brackets for that tooth come into view. Click on any one and a description will appear. Any bracket prescription may be chosen, no matter what the program has selected for you by answering the questions. When you change even one bracket from the computer generated prescription, you will see a change to “Custom-Designed Appliance” (above the clear button). If you want to return to the computer generated appliance (based on the answers to your questions and patient characteristics indicated in classification tabs), then click on “Computer-Generated Appliance” and the program will return to the programmed prescription.
All messages must be satisfied and cleared before the order can be sent.
If band sizes have not been added, then a message will appear that you must add this information for the order to be sent. You may add notes that will go with the order next to any tooth.
** You must correct all the messages given to you before you can place the order. For example, all band sizes must be added.
Step 9: Place Order
You must be connected to the internet to place an order. Click the “Place Order” button:
A window will appear with the patients’ name, asking for your “Confirmation Code” to place the order. Consider this the same as a signature on a drug prescription written by a physician. The confirmation code is typically the doctor’s last name (not the user ID). The order will automatically be placed into an order form and the appliance priced. Archwires and reorder brackets used from the repair kit will be automatically added. You may add additional items from the orthodontic supply to the order. After the order is confirmed complete, submit the order. Expect arrival within 7 calendar days.
The patient prescription is itemized and priced. On the above screen, you may change any quantities, remove or add individual items, or remove all. When confirmed, scroll to the bottom of the screen and click the “Check-out” button.
Currency conversion is tied to the Microsoft currency conversion rates.
Enter your ship-to address. The “Country” is a required field. When completed, click “Submit”.
Indicate the shipping method and click “Check-out”.
The final invoice is completed, with tax and shipping added. This is the best time to print your order (by clicking the print icon close to the upper left corner) because this screen shows your entire order.
Review the order. When confirmed, scroll to the bottom of the screen and click “Check-out”.
The above screen is for your own records only. Enter anything you want, like your purchase order number or the patient’s name. Then click Submit.
This is the last screen you see in the ordering process: your 4-digit order number. This is proof that your order has been accepted. Write down the order number in your patient file.
Step 10: Print Order (optional)
If you would like a hard copy of the patients’ prescription and heights, then you can choose to print the bracket and band prescription for your patient. Faxing this printed form for an order will generate a $20 service charge for the manual entry into the inventory and billing system. There is no such charge for e-commerce orders.