Orthodontic Practice US Summer 2021 Vol 12 No 2 by MedMark, LLC

PROMOTING EXCELLENCE IN ORTHODONTICS Minimum Touch OrthodonticsSM: A workflow philosophy that can transcend COVID-19 Katelyn’s story

Dr. Jep Paschal

Motion 3D™ & SLX® 3D with M-Series™

clinical articles • management advice • practice profiles • technology reviews Summer 2021 – Vol 12 No 2 • orthopracticeus.com

Dr. Todd Rankin

A comparison of digital-based treatments — Invisalign® versus LightForce® Dr. David Alpan

Evaluation of adverse physiological events during Invisalign® treatment: part 2 Drs. Bridgette Jones Brooks, Bryan Keith Blankenship, and Jared Stasi

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INTRODUCTION

Resilience and change — the key to recovery

Summer 2021 - Volume 12 Number 2

EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD

esilience is often defined as the “capacity to recover quickly from difficulties.” During the past year, we have all had a chance to reflect on our current experience, and many have predicted that this year will be a defining moment in our lives. I feel a key to our recovery is both resilience and change if we are to overcome these difficulties quickly and successfully. We quickly realize that previous generations have been very resilient. My grandparents were born in the 1890s, and I was blessed to have them living only two blocks away. I have been reflecting on their experiences lately. World War I started when they were teenagers, and my grandfather fought in WWI in France in 1917 until the end of the war that killed an estimated 22 million people. During the 10 weeks that our office was forced to close, beginning in March 2020, I read the love letters my grandmother wrote to my grandfather while he was in France. No complaints in any of the 100-plus letters — only hope for the future. My grandparents were married after the war only to live through the Spanish flu in 1918. Not a word was ever spoken of this pandemic tragedy that killed 50 million people. They experienced the Great Depression from 1929 to around 1934 with 25% unemployment. This period was followed by World War II (1939-1945), which killed 75 million people. The Korean War (1950-1953) killed 5 million, followed by the Vietnam War in which over 3 million people lost their lives. The assassinations of President John F. Kennedy (1964), Senator Robert Kennedy (1968), and Martin Luther King Jr. (1968) occurred as well as the race riots of the 1960s, which took place in the town adjacent to where my grandparents lived. As a child in the 1960s and 1970s, I experienced my grandparents as a wonderfully happy older couple who drove me to school and sports practices and would comfort me when I had a tough day at school. Never did they complain about their difficulties. I remember their joy at everyday meals, going for a swim in the ocean, and the joy they had for their family and friends. Previous generations have endured terrible problems and came out of it stronger and more resilient with a great view of what is important. We can do this. A willingness to change is another trait that has been valuable this past year. Our team began last June to examine every aspect of our practice and to decide what needed to change. As orthodontists, we all have a defined idea of how our office should run, how to obtain a good result, and what success will look like. This past year we have learned that the key to a successful recovery is to be very flexible with our patients and our team members while making appropriate changes. Some of the changes we have implemented are simple, such as using a self-etching primer for our clear aligner attachment bonding, which reduced an aerosol step, and there has been no change in success but an increase in efficiency. Our HVAC system was upgraded to kill 99.7% of bacteria and viruses, which has increased the comfort level for the team and patients while contributing to a decrease in team members’ sick days. We have embraced texting as our primary method of communication with our patients, and we received quicker responses than our previous email and phone calls. Virtual consultations have enabled patients to be properly scheduled for ongoing treatment or even the timing as to when to come for initial consultations. Our team members have had to be flexible in when they can come to work due to young children who are still not in school full time. This has forced a new level of efficiency, so we still have been able to treat a similar number of patients with fewer team members each day. Once we have a full team, this increased efficiency will translate into practice growth. The bottom line is that this past year has been a blessing, since it has forced many changes that we will keep as we recover from the pandemic. As the business man Jack Welch once said, “Willingness to change is a strength, even if it means plunging part of the company into total confusion for a while.” We must embrace this willingness to change if we are to have strong practices. I wish each of you the gift of resiliency while embracing the changes necessary to be successful. Mark W. McDonough, DMD, is an orthodontist who has been practicing in Pennington, New Jersey, since 1994. He earned his dental degree from the University of Pennsylvania, completed a General Practice Residency at Lenox Hill Hospital in New York City, and received his Certificate in Orthodontics from Albert Einstein Medical Center in Phildadelphia, Pennsylvania. He has been a part-time clinical instructor at Albert Einstein Medical Center in Philadelphia since 1995. Dr. McDonough is a Diplomate of the American Board of Orthodontics and past President of The Greater Philadelphia Society of Orthodontics as well as the Mercer Dental Society.

Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Bradford N. Edgren, DDS, MS, FACD Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Laurence Jerrold, DDS, JD, ABO Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Bradford N. Edgren, DDS, MS, FACD Fred Stewart Feld, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA Justin D. Moody, DDS, DABOI, DICOI Lisa Moler (Publisher) Mali Schantz-Feld, MA, CDE (Managing Editor) Lou Shuman, DMD, CAGS

© MedMark, LLC 2021. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

ISSN number 2372-8396

2 Orthodontic practice

Volume 12 Number 2

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TABLE OF CONTENTS

Cover story

Minimum Touch OrthodonticsSM (MTO): A workflow philosophy that can transcend COVID-19

Publisher’s perspective

Dr. Jep Paschal reimagined his practice workflow to achieve an enhanced patient experience

Lisa Moler, Founder/CEO, MedMark Media................................8

The Roaring 20s

Continuing education Evaluation of adverse physiological events during Invisalign® treatment: part 2

Banding together

Katelyn’s story

Drs. Bridgette Jones Brooks, Bryan Keith Blankenship, and Jared Stasi continue their exploration of the literature regarding clear aligners as compared to traditional braces ........................................................16

Dr. Todd Rankin shares a story of extraordinary teamwork and the stunning transformation of a young woman who had lost all hope ON THE COVER Cover image courtesy of Henry Schein® Orthodontics. Article begins on page 10.

4 Orthodontic practice

Volume 12 Number 2

Together We Run Better Businesses.

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TABLE OF CONTENTS Practice development Increase clear aligner compliance, results, and patient trust Dr. Diane Milberg discusses achieving compliance through making the right choices............................................28

Product profile Allesee Orthodontic Appliances (AOA) The latest retainer technology for your practice...........................................30

Continuing education A comparison of digital-based treatments — Invisalign® versus LightForce®

Dr. David Alpan shares his expertise with two digital tooth-moving technologies

Technology

Product profile

Treatment of a Class II malocclusion with a TruEase™ fixed bite corrector: case report

Running a digital practice without it running you

Drs. Emad Hussein, Sari Amer, Khaled Qatawi, and Yazan Ashhab discuss a non-extraction option that overcomes compliance problems......................32

Dr. David Defay discusses how switching to an in-office aligner software company saved him time and money while providing more creative freedom and versatility..................... 38

Technology profile The BRIUS System: independent tooth movement Introducing the first orthodontic system providing independent tooth movement....................................... 40

www.orthopracticeus.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter

CONNECT with us on social media Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

6 Orthodontic practice

Volume 12 Number 2

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PUBLISHER’S PERSPECTIVE

The Roaring 20s

Published by

ere comes summer — we’re already halfway through the year, and many of us have hit the ground running into 2021 — a robust reboot of the “Roaring 20s!” During this past year, we have all had plenty of time to think about our personal and professional lives, what works and what needs to be changed. It’s definitely time to get back to business. Here are some interesting and positive facts from an ADA Health Policy Institute survey collected in January. • Patients are back! As of the week of January 18, patient volume was estimated at 80% of pre-COVID-19 levels, on average. Staffing in dental offices was at 99% of preCOVID-19 levels, and four out of five employee dentists Lisa Moler were being paid fully. Founder/Publisher, MedMark Media • Dentists are realizing their worth! At the beginning of the year, nearly a third of dentists had raised fees. Those who needed some extra help were proactive, taking out loans, reducing their dental team hours, and changing suppliers to those more appropriate to their goals. Retirement rates have not changed due to COVID-19. • Practices are ready to roar! The sector has recovered nearly fully in terms of hiring and employment. Based on vaccine rollout and perceptions, full recovery of dentistry is anticipated by the summer or fall. Research and development continue to bring new products and techniques to dental specialties, and now, it’s time to figure out how to stay ahead in this very competitive marketplace. One valuable way is letting MedMark publications educate you about products, services, and techniques that can add to your armamentarium and boost your patients’ options. The more choices that patients have for treatment, the more ways that you can expand your practice’s scope and profits. This issue of Orthodontic Practice US features part 2 of the CE that explores the literature regarding clear aligners versus traditional braces. In another CE, Dr. David Alpan compares the digital-based treatments of LightForce Orthodontics versus Invisalign®. As tooth-moving tools continue to evolve, it’s important to know the benefits of these technologies individually and in combination. Our cover story by Dr. Jep Paschal shows how he reimagined his practice based on Minimum Touch OrthodonticsSM launched by Henry Schein® Orthodontics™. Read about the appliances and applications that supported his paradigm shift. Our technology column delves into a new pre-programmed CAD/CAM-based orthodontic system called BRIUS® that allows orthodontists to move teeth independently. Many aspects of traditional dentistry have changed over the past year, and clinicians were pushed to find ways to serve patients better while maintaining safe protocols. Applications like teledentistry, patient texting, and online consultations showed that you can stay connected to your patients and serve their needs with secure options. Patients have embraced new technologies and still want these benefits even as offices return to full business as usual. Methods for scheduling fewer appointments and less chair time, while maintaining the personal connection with patients, have been created with more creativity and success that will continue into the future. While 2020 started out as one of the most unusual in our lives, 2021 promises continued healing and the potential for great success. Let us help you get ready to roar into the future with high expectations! To your best success, Lisa Moler Founder/Publisher MedMark Media

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PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA, CDE mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com MANAGER CLIENT SERVICES/SALES Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING & DIGITAL STRATEGY Amzi Koury amzi@medmarkmedia.com WEBMASTER Mike Campbell webmaster@medmarkmedia.com EMEDIA COORDINATOR Michelle Britzius emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.medmarkmedia.com www.orthopracticeus.com SUBSCRIPTION RATES 1 year (4 issues) $149 3 years (12 issues) $399 Subscribe at https://orthopracticeus.com/subscribe/ Volume 12 Number 2

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COVER STORY

Minimum Touch OrthodonticsSM (MTO): A workflow philosophy that can transcend COVID-19 Dr. Jep Paschal reimagined his practice workflow to achieve an enhanced patient experience

inimum Touch OrthodonticsSM (MTO) is an orthodontic workflow philosophy Henry Schein® Orthodontics™ (HSO) launched, under the guidance of its clinical advisory orthodontists, to assist orthodontists in focusing their efforts during the pandemic toward one goal — to deliver simplified, predictable results in fewer and shorter appointments with reduced treatment times, while maximizing virtual appointments for superior patient convenience and enhanced patient experiences. For Dr. Jep Paschal, the true value of MTO evolved over time. Already using innovative appliances and efficient mechanics, he had thought of MTO primarily in terms of minimizing treatment time. When he and his team reevaluated their workflow according to patient needs during COVID-19, they began to embrace the MTO concept of convenience more holistically. How often could they substitute virtual appointments for physical appointments? What multiple technologies would allow them to do that simply and effectively? How could they make each physical appointment shorter and less invasive? What about scheduling? Same-day starts? Using MTO as the model, patient communications have changed dramatically in the Paschal practice over the last year. Virtual consults have become an option with significant reliance on texting, email exchanges, and Google Meet, plus targeted use of remote monitoring solutions such as Dental Monitoring™ (DM) and Grin,

Dr. Jep Paschal received his Bachelor of Science degree from Emory University in 1989 and his Doctorate of Medical Dentistry in 1993 from the Medical College of Georgia, where he graduated with honors, received many scholastic achievement awards, and was one of a few select students inducted into the National Dental Honor Society, Omicron Kappa Upsilon. Dr. Paschal continued his education at the University of Texas Health Science Center at San Antonio. There, he completed a residency in Prosthodontics (a specialty in restorative dentistry and implants) in 1996, a Master of Science degree in Biomaterials and Prosthodontics, and a General Practice Residency in 1997. Dr. Paschal maintained a private practice in Prosthodontics and Reconstructive Implant Dentistry in Atlanta for 5 years before returning to graduate school to complete a residency in Orthodontics at the University of Rochester Eastman Dental Center. Dr. Paschal currently maintains a private orthodontic practice in both Madison and Lake Oconee, Georgia. Disclosure: Dr. Paschal is a key opinion leader for Henry Schein®.

10 Orthodontic practice

which offers a convenient and cost-effective platform that enables superior patient care while supplying orthodontists the tools to scale their practice.“We hand out disposable cheek retractors like candy,” Dr. Paschal teases, “because we encourage patients to approach us virtually if they prefer. This has been a huge cultural shift for our practice, but one that has been extremely well received by patients and parents.”

Same-day starts made practical

Same-day starts (SDS) are fundamental to patient convenience and MTO. The SAGITTAL FIRST™ concept, fueled by the Carriere® Motion 3D™ Appliance for A/P correction, makes same-day starts practical. Using the Motion 3D Appliance to establish a CL I platform prior to completing treatment in aligners or braces simplifies finishing and can considerably reduce overall treatment time. From their first patient interactions, the Paschal team communicates that patients can start same day. “Not only are SDSs good for profitability, they’re what people want now given that online options such as Smile Direct Club™ and Candid™ are available,” Dr. Paschal explains. “Motion 3D has been essential to getting our SDS numbers from 55% to 75% because Motion takes only 15 minutes to bond (4 minutes for me) and fits easily into the schedule.” With fast in-house printers, the Paschal team can deliver the opposite-arch aligner on the same day. Using Motion 3D to satisfy MTO also minimizes the number of treatment-planning decisions. With the Motion 3D Appliance, there is no protocol change for different malocclusion types. “I don’t need to determine how I’m going to resolve the A/P for each patient,” Dr. Paschal adds. “If there’s an A/P issue, we utilize Motion 3D.” It was Dr. Luis Carrière, the Motion 3D Appliance inventor, who introduced Dr. Paschal properly to Motion 3D. “My practice was transformed that day,” Dr. Paschal said. ”I was looking at Luis’s cases, his results, and timelines. I wasn’t getting those results, and I wasn’t getting remotely close to his timelines. We were using Carriere SLX® 3D brackets and the same archwires. The only variable was the Motion 3D Appliance.”

Dr. Jep Paschal

Appliances that support MTO For many years, Herbst had been the A/P treatment appliance of choice for most clinicians if simple elastics weren’t suitable or surgery wasn’t indicated. “Motion 3D fostered a paradigm shift in my practice,” Dr. Paschal affirms. “We went from 12 months for Herbst correction to 4 to 6 months with Motion 3D, cutting A/P treatment time in half (Figure 1). We’re now seeing 14 to 16 months for average overall treatment times with either braces or aligners, even with a full-step CL II.” Having to make the alignersversus-braces choice during the consult had always been a sticking point. Motion 3D has removed this barrier because patients don’t need to make this decision until the end of Motion treatment. The Motion 3D Appliance standardizes workflow, making it predictable. CL II — even full-step CL II — CL III and unilateral cases can be accommodated. The appliance also lends itself to remote monitoring, further reducing physical appointments. Miranda Bacon, Treatment Coordinator for Paschal Orthodontics and former Clinical Assistant, continues, “Motion 3D takes only 4 minutes of doctor time to bond, so it’s definitely minimum touch, and we can use it for both adults and kids, even kids in mixed dentition. We tell patients, ‘If you Volume 12 Number 2

reduced the fee schedules for full dentition cases to two, so that Ms. Bacon can confidently quote fees regardless of the complexity of the case.

Clear aligners and virtual monitoring

After CL I is achieved, patients can complete treatment in Reveal® Clear Aligners, other aligners, or fixed appliances. HSO’s Reveal Clear Aligners are a cost-effective treatment solution, designed to treat mild to complex malocclusions. They are recognized for advanced clarity, comfort, and superior tooth adaptation, especially interproximally, reducing the need for unsightly attachments. Aligner cases offer an excellent opportunity for remote monitoring and MTO. Dr. Paschal follows aligner cases using Dental Monitoring (DM) and brands all remote monitoring as Paschal Remote. For one patient, Paschal Remote can be a smartphone and cheek retractors. For another, it can mean Dental Monitoring. To his patient, it’s all Paschal Remote. Dr. Paschal finds that virtual monitoring more closely ties the patient to the practice than he would have anticipated. “You would think that remote monitoring would make the patient less involved with the practice because there are fewer physical contacts,” Dr. Paschal acknowledges, ”but we’re finding that patients actually have more interaction with our office through virtual

monitoring because the DM app reaches out to them weekly to take action.” Ms. Bacon adds, “If the patient had a bad week or was on vacation, for example, and didn’t wear the aligners as required, remote monitoring can prompt us to extend aligner wear for a few days. For in-house aligner cases, it takes the guesswork out of when to schedule the patient for the new set. DM lets us track progress, and we work ahead, so we don’t lose time with the patient being in aligners that are only acting as retainers at that point.”

A straightforward wire sequence If the choice to complete treatment is fixed appliances, HSO offers the Carriere SLX 3D Self-Ligating Bracket System, which now includes PSL first molar tubes (Figure 2). Dr. Paschal feels SLX 3D Brackets greatly expand his scope of care, specifically in minimizing extractions. SLX 3D Brackets feature the Carriere M-Series™ Wires, a 3-wire sequence, that make it a complete system with standardized protocols. The critical pain point for most orthodontists is wire sequence. M-Series is straightforward: M1, M2, M3. There are additional wires for expansion, severe rotations, etc., and the newly introduced overexpressed wires for crossbites. This three-wire series translates to a predictable workflow, easier team communication, ordering and inventory control. The cornerstone of the three-wire sequence is the M2 (0.020” x 0.020”) archwire. “With the self-ligation system I used previously,” Dr. Paschal explains, “the door was not wide enough to take advantage of this size wire. With Motion 3D stimulating interstitial fibers, cases can move into the M1 wire, a larger dimension starting wire (0.015”) than is typical for PSL, then the team can insert the M2 wire even with brackets slightly out of alignment far earlier in treatment for easier and faster finishing. Because the mesial-distal dimension of the SLX 3D bracket is designed to accommodate this square wire, it fully engages it. M3, the final adjustable wire, then finishes treatment. We treat more than 60% of our cases with this three-wire sequence to excellent results. No guesswork. Minimum Touch.”

MTO beyond this time

Figure 1: Class I achieved in 3.5 months with Motion 3D Appliance Volume 12 Number 2

Figure 2: Total Tx 17 months: 3.5 months Motion 3D + 13.5 months SLX 3D brackets

Convenience and personal experience have long been the driving forces behind consumers’ purchasing decisions. The pandemic made it more so. Using MTO as a lens through which to reimagine practice workflow can satisfy patients’ even greater need for convenience. That and patients’ new openness to digital communications can offer opportunities that should serve practices well beyond this time. OP Orthodontic practice 11

COVER STORY

wear it, it works.’ It’s gas to a Porsche; the charger to an iPhone. It does require patient compliance, but adults have just invested in treatment, so they’re highly motivated, and you might be surprised, but kids are so ready to get their braces or aligners, they usually wear their elastics as they should.” Since SAGITTAL FIRST dictates that Motion 3D be used prior to brackets or aligners, it’s simple for patients to see progress, which helps keep them engaged and fosters compliance. “Transitioning to Motion 3D removed the only true emergency in our practice,” Dr. Paschal explains. If Motion debonds, there is no must-see visit. The patient is simply told to remove it, stop wearing elastics, and schedule the 10-minute rebond. “I love it when we’re the second opinion, and Miranda shows the Motion 3D Appliance versus Herbst,” Dr. Paschal smiles. “When prospective patients see the difference, they sigh in relief. ‘Everyone at my lunch table has one,’ they tell us. Motion 3D starts up to 70% of our patients these days. When I think how far we’ve come in only a few years, I marvel at the improvements.” In terms of same-day starts for CL I patients who don’t require Motion 3D, the Paschal team takes facial photos and a scan at the start of every consult, so can move forward quickly, whether the patient wants aligners or braces. Dr. Paschal has

BANDING TOGETHER

Katelyn’s story Dr. Todd Rankin shares a story of extraordinary teamwork and the stunning transformation of a young woman who had lost all hope

started having a feeling that my smile wasn’t like everyone else’s pretty early in the game. I always looked in the mirror, I always looked at magazines with the girls on the front with these big beautiful teeth, and I always thought — is there anything I can do? — Katelyn Katelyn first visited us as a 12-year-old with no confidence and little hope that she would ever have the beautiful smile she so desperately wanted. After getting picked on for many years because of her odd smile and missing teeth, she was reluctant to even show me her mouth to get a look at the work that needed to be done. When I met Dr. Rankin, I felt intimidated even by the thought that someone would have to examine what I’ve been hiding. Without hesitation, he told me he knew how I felt. All the doctors involved in my case were constantly there for me and helped me in more ways than they will ever know. — Katelyn Katelyn’s mom wasn’t sure they could afford braces, let alone all of the other procedures that her daughter needed. This is when I told them about Smile for a Lifetime and their mission of giving the gift of a smile to youth in need. When she and Katelyn learned that the transformation would be free for them and performed by a team of volunteer professionals, they were overwhelmed. No one should ever have to hide their smile from the world. It was time to change that for Katelyn, and I was confident that our team could accomplish this. Katelyn’s case was very complex and beyond what I could do myself. With 19 missing teeth due to ectodermal dysplasia, a severe maxillary Todd Rankin, DDS, received his undergraduate degree from Bucknell University and his Doctorate of Dental Surgery from the University of North Carolina School of Dental Medicine. There he received an award from the American Association of Orthodontists for exceptional research in facial development. He received his certificate in orthodontics at the University of Connecticut Health Center. Dr. Rankin is a member of both the American Association of Orthodontists and North Carolina Association of Orthodontists (past president of NCAO). He is also a longtime member of the Schulman Study Group of orthodontists and is in practice at Rankin and Fiume Orthodontics in New Bern, North Carolina.

12 Orthodontic practice

Figure 1: Katelyn

Figure 2: Pre- and posttreatment

deficiency, and limited dental care to her present teeth, I knew I needed a stellar team to give Katelyn the smile of her dreams. Her treatment plan would require orthognathic surgery with multiple implants, bilateral sinus grafts, and ridge augmentation followed by extensive restorative work. We were very fortunate to partner with an incredible interdisciplinary team of professionals and hospitals for Katelyn’s case. Dr. William Foley, our Oral Maxillofacial Surgeon, came onboard to donate his services for the orthognathic surgery, and the local hospital administrator, Mr. Ray Legget, graciously donated all hospital services during Katelyn’s stay. Dr. Jeffery R. Thomas with Wilmington Periodontics & Implant Center agreed to

give his time and worked with Straumann® USA (Andover, Massachusetts) to donate all needed implants, their components, and regenerative materials for Katelyn’s case. When Dr. Rankin introduced me to Katelyn, I was not surprised but became aware quickly of the vast enormity of the project. It was essentially not just a highly complex full-mouth endeavor, but a challenge to somehow psychologically bring an understanding to a young lady, who did not care about her life at all. — Dr. Jeffrey R. Thomas The final piece of the puzzle was our Cosmetic Reconstructive Dentist, Dr. J. Stephen Hoard, with J. Stephen Hoard Cosmetic and Restorative Dentistry, who donated his services and arranged for Volume 12 Number 2

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BANDING TOGETHER

Figure 3: Pre- and posttreatment cephs Figure 4: Pre- and posttreatment panoramic radiographs

Figure 5: (left to right) Dr. Leonard “Len” Fiume, Dr. Todd Rankin, Katelyn, Dr. Jeffrey R. Thomas, and Dr. J. Stephen Hoard

Bay View Dental Lab (Chesapeake, Virginia) to cover all lab fees. Dr. Rankin had discussed her case with me before I saw her. He wanted to know if I was willing to help out with a case through the Smile for a Lifetime program. I was already part of a tremendous dental team that included Orthodontist Dr. Todd Rankin, Periodontist Dr. Jeffrey Thomas, Oral and Maxillofacial Surgeon Dr. William Foley, Bay View Dental Lab, and myself, a restorative dentist, so it was already a “yes” from me before he asked. — Dr. J. Stephen Hoard November 2015 marked one of the most satisfying and emotional milestones of Katelyn’s transformative journey. With the help of Dr. Hoard, Bay View Dental Lab, and Dr. Thomas, the upper provisional was placed, allowing Katelyn to have some new teeth while the rest of the reconstruction was taking place. As Katelyn saw her teeth for the 14 Orthodontic practice

first time, it was an explosion of emotions — laughing, crying, and total disbelief. In that instant, the shy young girl was gone forever. Born was a self-confident young woman. — Dr. J. Stephen Hoard We were all completely blown away, and there was not a dry eye in the room. This transformation was a shift in the universe for Katelyn, her mom, and the treatment team, and Smile for a Lifetime that cannot fully be described or quantified. The moment I got to see myself with a smile was the moment I began breaking out of my shell, and I felt like I could take on the world. — Katelyn Katelyn’s remarkable esthetic outcome as well as the dedication and teamwork of everyone involved was a priceless and a completely life-changing experience for all of us. It transformed a child who had no desire to continue living into a vibrant and outgoing woman who now works as a dental assistant

in an oral and maxillofacial surgery practice. The icing on the cake was when Straumann® and the National Foundation for Ectodermal Dysplasia selected her for an all-expenses paid trip to San Francisco to take the stage at the Straumann®/ITI National Meeting and tell her story. Her remarkable testimony and dazzling smile had many people in tears! We all try to change people’s lives every day. The Smile for a Lifetime program allows you to do this through a team approach in dentistry, and our reward goes beyond any financial compensation we ever could receive. I look forward to our next case. — Dr. J. Stephen Hoard This case was the ultimate interdisciplinary experience, demonstrating how we really need each other to achieve high-level treatment outcomes for complex patients. Katelyn’s case spanned nearly 6 years and encompassed donated goods and services worth at least $180,000. More importantly, it changed her life and gave her hope for a promising future. If you watch Katelyn’s video on the S4L website (smileforalifetime.org), you may shed a tear as well. Katelyn’s incredible story and transformation is the reason we do what we do at Smile for a Lifetime. We have expanded our volunteer base to include dentists and oral surgeons to better serve kids in need. Working in interdisciplinary teams, providers can deliver more comprehensive oral health care to complex patients like Katelyn. — Robin Coen, National Executive Director, Smile for a Lifetime Foundation To learn more about the mission of Smile for a Lifetime and how you can become a provider, or to watch Katelyn’s touching smile transformation, visit https://www.smilefora lifetime.org. OP Volume 12 Number 2

Innovation. Quality. Service. 1985

Purchased lingual laboratory division from Ormco™

1998

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1996

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2005

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2019

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Maintaining status as digital leader in 3D orthodontic laboratories

CONTINUING EDUCATION

Evaluation of adverse physiological events during Invisalign® treatment: part 2 Drs. Bridgette Jones Brooks, Bryan Keith Blankenship, and Jared Stasi continue their exploration of the literature regarding clear aligners as compared to traditional braces Introduction The aim of this study is to review the appropriate literature concerning adverse physiological events experienced by patients being treated with Invisalign® appliances and comparing this literature to that of patients’ adverse physiological events when undergoing fixed orthodontic appliance therapy. Part 1 discussed various areas of treatment, efficacy, effectiveness, and oral hygiene, including orofacial pain/discomfort, periodontal health, dental caries and demineralization, and interproximal reduction (IPR) adjunct in Invisalign therapy and its impact upon oral health. Read part 1 here: https:// orthopracticeus.com/ce-articles/evaluationof-adverse-physiological-events-duringinvisalign-treatment-part-1/. Part 2 of this article will continue with the discussion and findings of the individual studies and some conclusions regarding Bridgette Jones Brooks, DMD, is a graduate of Spelman College with a Bachelors’ degree in Psychology. She attended East Carolina University School of Dental Medicine where she obtained her Doctorate of Dental Medicine and then completed a General Practice Residency at Mountain Area Health Education Centers. She completed her orthodontic training at the Georgia School of Orthodontics where she received a certificate in Orthodontics and Dentofacial Orthopedics. She currently practices in the metropolitan Atlanta, Georgia, area. Bryan Keith Blankenship, DDS, is an alumnus of The Ohio State University (DDS) and Bachelor’s and Master’s degrees in Microbiology. He is a graduate of the Georgia School of Orthodontics (Class of 2020). Dr. Blankenship currently practices orthodontics in Palm Coast, Florida. Jared Stasi, DDS, earned a Bachelor of Science and his dental degree from Creighton University. He received a certificate in Orthodontics and Dentofacial Orthopedics from the Georgia School of Orthodontics (Class of 2020). Dr. Stasi currently practices orthodontics in Centennial, Aurora and Silverthorne, Colorado. Disclosure: None of the authors has any financial interest in Invisalign® (Align Technology Inc.).

16 Orthodontic practice

Educational aims and objectives

This self-instructional course for dentists aims to show research that studied the differences in discomfort, periodontal health, or caries/demineralization experienced by patients who were being orthodontically treated with Invisalign® as compared to traditional fixed appliances.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions by taking the quiz online at orthopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • • • •

Realize what some studies have found regarding orofacial pain/discomfort with clear aligners or traditional braces. Realize what some studies have found regarding periodontal health with clear aligners or traditional braces Realize what some studies have found regarding caries/demineralization with clear aligners or traditional braces. Realize what some studies report regarding maintaining an appropriate level of oral hygiene with either clear aligners or traditional braces.

orofacial pain, periodontal health, and caries/ demineralization.

Discussion and findings: Orofacial pain “A comparison of treatment impacts between Invisalign aligner and fixed appliance therapy during the first week of treatment”1 This study was a prospective longitudinal cohort study involving adult orthodontic patients. The purpose of this study was to evaluate through survey and diary entries the differences in quality of life impacts between subjects treated with Invisalign aligners and those with fixed appliances during the first week of orthodontic treatment. Overall, Invisalign patients reported less of a quality-of life decrease during the first week of treatment, and fixed appliance patients reported more analgesic use. The findings of this study are pertinent to the orthodontic practitioner in that the practitioner gains knowledge as to how to relay information and expectations to the patient regarding initial quality of life changes due to orthodontic treatment. Few studies are of this nature and evaluate the first 7 days of treatment. Limitations of this study include the

subjective nature of individual pain perception and inability to apply results toward treatment after the first week. “Adult patients’ adjustability to orthodontic appliances. Part I: a comparison between Labial, Lingual, and Invisalign”2 This study was a prospective longitudinal study that examined the adult patient’s perception of recovery after insertion of three types of orthodontic appliances: buccal, lingual and Invisalign. The purpose of this study was to evaluate through survey with visual analog scale the differences in pain perception and recovery between the three different types of orthodontic appliances. Overall lingual appliances were associated with the worst perceived pain and oral disturbances. Invisalign as well as buccal appliances were less than lingual in these categories and similar in perceived levels to each other. The findings of this study are pertinent to the orthodontic practitioner in that the practitioner gains knowledge as to how to relay information and expectations to the patient regarding expected pain during treatment and between different the three studied Volume 12 Number 2

“Analysis of pain level in cases treated with Invisalign aligner: comparison with fixed edgewise appliance therapy”3 This study was a prospective longitudinal study that examined the adult patient’s perception of pain during treatment with edgewise or Invisalign appliances. The study also identified common sources of pain associated with Invisalign treatment. The aim of this study was to evaluate and compare the difference in the level of pain using the visual analog scale (VAS) between cases treated with the edgewise appliance and Invisalign. Overall Invisalign may offer less pain in comparison to edgewise appliances specifically after adjustments. Most pain associated with Invisalign was found to be deformation of the tray. The findings of this study are pertinent to the orthodontic practitioner in that the practitioner gains knowledge as to how to relay information and expectations to the patient regarding expected pain during treatment and between the two studied treatment options. Several studies have attempted to determine which treatment option delivers the least pain. Present studies have conflicting results as to which appliance results in less pain. Limitations of this study include the subjective nature of individual pain perception and possibly standardization of complexity of the presenting malocclusion for treatment, as the practitioner is likely to exclude certain treatment options based upon complexity of perceived treatment. “Discomfort associated with Invisalign and traditional brackets: a randomized, prospective trial”4 This study was a prospective randomized equivalence two-arm parallel trial. This study examined the adult patient’s perception of pain with visual analog scale during treatment with traditional fixed orthodontic appliances or Invisalign. Overall, Invisalign may offer less pain in comparison to traditional orthodontic appliances specifically after adjustments. The Volume 12 Number 2

intensity of pain appeared to decrease over time after the 2-month time frame. Patients treated with traditional appliances may also consume more analgesics in comparison to patients treated with Invisalign. The findings of this study are pertinent to the orthodontic practitioner in that the practitioner gains knowledge as to how to relay information and expectations to the patient regarding expected pain during treatment and between the two studied treatment options. Several studies have attempted to determine which treatment option delivers the less pain. Present studies have conflicting results as to which appliance results in less pain. Limitations of this study include the subjective nature of individual pain perception and that patients treated with either appliance in comparison are not identical or “twins.” Pain perception was identified after adjustments for the traditional group, but it is unclear how the patients in the Invisalign were tracked or instructed to change trays. Consistently changing trays over time may allow for increased pain threshold in comparison to adjustments with traditional appliances. This study was also self-reported to not be registered.

Discussion and findings: Periodontal health “Braces versus Invisalign®: gingival parameters and patients’ satisfaction during treatment: a cross-sectional study”5 This study was a cross-sectional study involving adult orthodontic patients. The purpose of this study was to evaluate differences in oral hygiene and patient satisfaction

between subjects treated with Invisalign aligners and those with fixed appliances. Reports about the effects of aligner treatment on oral hygiene and gingival conditions are minimal and conflicting. The findings of this study are pertinent to the orthodontic practitioner in that the practitioner gains knowledge as to how to relay information and expectations to the patient regarding changes in oral health due to orthodontic treatment. The findings suggest Invisalign and fixed appliances have similar plaque measurements, but that fixed appliances demonstrated a worse gingival condition. One primary limitation in this study is propensity for examiner bias. Due to obvious visual differences between Invisalign and fixed appliances, one clinical examiner can be prone to selection bias. A better but likely unrealistic study would suggest removal of all indications as to what treatment was occurring, such as removing all fixed appliances and attachments prior to clinical exam. Limitations of this study also include the subjective nature of oral hygiene. Patients in the fixed appliance group were on average 15 years younger than the Invisalign group, 16 years of age and 31 years of age respectively. Patients were controlled for initial oral hygiene, but better parameters should have been implemented to track and standardize daily oral hygiene differences such as duration and quality of daily oral hygiene maintenance. Older individuals may be more personally and financially invested in treatment outcomes, suggesting Invisalign patients may be more attentive to oral hygiene maintenance than adolescent Orthodontic practice 17

CONTINUING EDUCATION

treatment options. Few studies compare different pain perceptions between the three treatment options as well as analgesic use. Limitations of this study include the subjective nature of individual pain perception and possibly standardization of complexity of the presenting malocclusion for treatment as the practitioner is likely to exclude certain treatment options based upon complexity of perceived treatment.

CONTINUING EDUCATION counterparts. Additionally, complex hormonal changes are often occurring during the average age range of the fixed appliance group (16) in which plaque may unequally exacerbate gingival response in comparison. “A comparison of the periodontal health of patients during treatment with the Invisalign system and with fixed lingual appliances”6 This study was a prospective longitudinal concomitant trial of two groups of consecutive patients. The purpose of this study was to evaluate periodontal health of patients during treatment with the Invisalign system or fixed lingual appliances. The findings of this study are pertinent to the orthodontic practitioner in that the practitioner gains knowledge as to how to relay information and expectations to the patient regarding oral health changes due to orthodontic treatment. Relatively few studies evaluate the differences between fixed lingual appliances and Invisalign. Limitations of this study include the subjective nature of oral hygiene maintenance and quality of self-care. It is unclear if the examiners were standardized to perform the clinical exams, and due to the visual differences of each treatment modality, observers may be prone to examiner bias. “Periodontal health during clear aligners treatment (CAT): a systematic review”7 The purpose of the study was to perform a systematic review of the existing literature in order to assess periodontal health during clear aligner therapy. The findings of this study are pertinent to the orthodontic practitioner in that the practitioner gains knowledge as to how to relay information and expectations to the patient regarding oral health changes due to orthodontic clear aligner therapy treatment. Relatively few studies, five in this review, have successfully evaluated periodontal health during clear aligner treatment. Most of the studies presented with methodological problems: bias and confounding variables, lack of adequate blinding procedures, and absence of proper randomization methods. Thus, conclusions with a moderate level of evidence could be drawn from the review process. Five relevant articles were selected from the 1,247 identified articles. The level of evidence was moderate for all the studies. A significant improvement of the periodontal health indexes was revealed, in particular when CAT was compared to fixed appliances. 18 Orthodontic practice

No periodontal CAT adverse effects were observed in the selected studies. Periodontal health indexes were significantly improved during CAT. Limitations of the study are the number, quality, and heterogeneity of the included studies. “Ultrastructure and morphology of biofilms on thermoplastic orthodontic appliances in ‘fast’ and ‘slow’ plaque formers”8 This study was a scanning electron microscopy investigation involving adult orthodontic patients. Fifty-six Chinese male/ female volunteers (aged 19-39 years) were screened for their plaque-forming rate using the plaque percentage index (PPI) coupled with digital photography and computerbased image analysis, after a period of 48 hours of abstinence from oral hygiene procedures. Eleven volunteers (seven males/four females) representing the lowest and highest ends of the plaque formation spectrum were chosen as slow and fast plaque formers, respectively. The findings of this study are pertinent to the orthodontic practitioner in that the practitioner gains knowledge as to how to relay information and expectations to the patient regarding potential oral health changes due to orthodontic treatment specifically with clear aligner treatment. The orthodontic practitioner can also inform patients about their own oral health maintenance. Additionally, patients can be directed with the cleaning of aligners as well as direction as to where on the aligner to specifically target during daily cleaning. Few studies have researched biofilm accumulation and differences in composition between slow and fast plaque formers. Limitations of this study may be the differences in chemical composition of different proprietary aligner systems which may influence plaque formation and adherence. “Periodontal health status in patients treated with the Invisalign® system and fixed orthodontic appliances: a 3 months' clinical and microbiological evaluation”9 This study was a prospective longitudinal study involving adult and non-adult orthodontic patients. Seventy-seven patients were recruited for this study, 52 females and 25 males with an age range of 16-30. The findings of this study are pertinent to the orthodontic practitioner in that the practitioner gains knowledge as to how to relay information and expectations to the patient

regarding potential oral health changes due to orthodontic treatment specifically when comparing fixed appliances with clear aligner treatment. The orthodontic practitioner can also inform patients about their own oral health maintenance and possible increased attention to thoroughness for patients with fixed appliances. The Invisalign® group showed better results in terms of periodontal health and total biofilm mass compared to the fixed orthodontic appliance group. A statistically significant difference (P < 0.05) at the T2 in the total biofilm mass was found between the two groups. Some limitations of this present study are potential for bias due to one examiner performing all clinical exams with easily distinguishable treatment types. The mean age of patients was 24.3, but the mean age of each group of patients was not reported. This could possibly lead to irregularities between the two groups. Adult patients may be more motivated to assist in their own oral health maintenance as they are likely also financially invested in the treatment and self-motivated to approve their appearance. Patients in late teenage years often have hormonal changes that are also associated with increased gingival inflammatory response when plaque accumulates. Traditionally younger patients are also more likely to be treated with fixed appliances rather than Invisalign. Invisalign patients are often more esthetically driven and may exhibit better oral hygiene maintenance. “Which orthodontic appliance is best for oral hygiene? A randomized clinical trial”10 The aim of this prospective randomized clinical trial was to compare the effects of clear aligners, self-ligated brackets, and elastomeric-ligated brackets on patients’ oral hygiene during active orthodontic treatment. There was no evidence of any significant difference in the oral hygiene levels among clear aligners, self-ligated brackets, and conventional (elastomericligated) brackets after 18 months of active orthodontic treatment. Overall, there was not enough evidence to reject the null hypothesis that the type of orthodontic appliance has no effect on periodontal health. This study had two calibrated examiners perform all clinical exams. The examiners could not be blinded to the type of appliances being used to treat the patient, so this could be a potential area of bias. From previous studies, it can be confirmed that some patients also Volume 12 Number 2

Discussion and findings: Caries “A case of severe caries and demineralization in a patient wearing an Essix-type retainer”11 This study was a case report on an 18-year-old male patient. Consequently, this study does not carry a high level of evidence. Nevertheless, the reported patient had previously been orthodontically treated. The patient was wearing Essix retainers for roughly 20 hours per day and reported infrequent removal other than to eat. The patient also reported having multiple carbonated sugary beverages per day. The full coverage of the Essix retainer allowed beverages to pool within the retainer. Normally the oral environment would thoroughly cleanse these beverages from tooth surfaces; however, due to the full coverage nature of the retainer, this could not occur. The patient had extensive generalized caries that went undiagnosed due lack of regular office visits with his dentist. This case report is a valuable example for the orthodontic patient and practitioner. It is of extreme importance that the patient be informed of proper wear and care instructions for all Essix-type retainers as well as clear aligners. “Dental health assessed after interproximal enamel reduction: Caries risk in posterior teeth”12 This study was a retrospective cohort study clinical comparison with control. Fortythree consecutive patients aged 19 to 71 with IPR accomplished 4 to 5 years ago as part of orthodontic treatment were examined radiographically. Overall there was no evidence to suggest mesiodistal enamel reduction within suggested limits will cause harm to the teeth and supporting structures. Caries were found in only three patients treated with interproximal reduction. Some limitations of this study are related to the methods of examiner standardization. There was mention of only one dentist examiner who detected caries intraorally and by radiograph. There was only one examiner mentioned reading radiographs which is subject to intra-examiner bias. There was Volume 12 Number 2

The findings of this study (and others) are pertinent to the orthodontic practitioner in that the practitioner gains knowledge as to how to relay information and expectations to the patient regarding initial quality of life changes due to orthodontic treatment. no mention of how the single examiner was calibrated. Additionally, interproximal caries detection by explorer and light by a single examiner is subject to much variation and subjectivity.

With having 10 years as a follow-up to the study, results also show the irregularity index of 0,67 (DS 0.64). This study appears to have validity and a foundation for support of the null hypothesis.

“Caries risk after interproximal enamel reduction”13 This study was a retrospective cohort study. Forty patients treated with air rotor stripping were examined clinically 12 months after orthodontic treatment concluded. The study found that there is no significant risk of caries with ARS. Additionally, fluoride was suggested to have minimal-to-no benefit in patients that had ARS done. The orthodontic practitioner can apply this gained knowledge to treatment modalities and assurance to patients. Control trials were suggested for further research on application of fluoride. One limitation of this study was the use of a single examiner for all radiographic and clinical examination although the examiner was calibrated. Further investigation on the application of fluoride after ARS would be suggested.

“Atomic force microscopy analysis of enamel nanotopography after interproximal reduction”15 This study measured the differences in roughness of enamel surfaces treated with interproximal reduction using different reduction techniques and reduction tools. The roughness was measured using atomic force microscopy and analyzed the enamel nanotopography of treated enamel. Results would be as expected in that diamond coated burs resulted in the roughest enamel, while enamel treated with Sof-Lex™ Discs (3M) after the enamel reduction resulted in a smoother than untreated enamel. Range of roughness from highest to lowest are a result of the following: Larger Grit Medium Diamond Burs > Medium Strips > Fine Diamond Burs > Fine Strips and Mesh Discs = Fine Strips and Curved Discs > Control Surface > Sof-Lex Discs (Entire Series). No mention of fluoride use or any other treatment post enamel reduction or polishing. Due to the nanotopography, a careful consideration of test subjects should have been considered. Teeth can vary even within a subject and have multifactorial items to be considered such as oral hygiene, enamel wear, age, and nutritional resultant wear. The article stated strict exclusions in the methods which enhanced the results and conclusions of the project.

“Dental health assessed more than 10 years after interproximal enamel reduction (IPR) of mandibular anterior teeth”14 This study was a retrospective cohort study. Sixty-one patients had stripping (enamel reduction) of all six anterior teeth on the mesial and distal surfaces greater than or equal to 10 years prior. The results were compared to a reference group of sixteen students. The study found that no carious lesions were noted, no evidence of root pathology, the distance between roots were significantly greater in patients who had stripping of the anterior teeth, and 59 of the patients experienced no sensitivity with temperature differences. No iatrogenic damage was noted. Overall irregularities of the incisors were minimal.

“Air-rotor stripping and enamel demineralization in vitro”16 This was an in vitro study evaluating the effect of air-rotor stripping of enamel. An in vitro caries model was used to assess the susceptibility to demineralization. Air-rotor Orthodontic practice 19

CONTINUING EDUCATION

form plaque at different amounts and rates than others, and therefore, this could lead to potential flaws as not all patients can be realistically standardized. This study does afford the orthodontic practitioner knowledge to present to patients concerned about oral health in relation to different orthodontic treatment options.

CONTINUING EDUCATION stripping was performed on one surface of each extracted tooth with enamel reduction of 0.5 mm. These teeth were then introduced to demineralizing gel for various lengths of time and evaluated using microradiography and computerized image analysis (double window technique). Each abraded surface of all time frames resulted in a greater depth of demineralization and less mineral density. A second experiment using fluoride on the abraded surface showed a reduction of lesion penetration on abraded and control surfaces. This study demonstrates the negative effect and increased susceptibility of demineralization to air-rotor stripping of interproximal surfaces. However, it was not a longitudinal study, and long-term effects were not studied.

Conclusion Orofacial pain Four studies were included in this literature review. Of the four studies, three were in agreement that Invisalign caused less pain than fixed appliances. However, in one study, there was not a statistical difference between Invisalign and the fixed appliance groups. Increased analgesic use was attributed to the fixed appliance group in two of the three studies that reported analgesic use. Significant potential for bias and limitations of the subjective nature of pain require a cautious approach to accepting or rejecting the null hypothesis. In conclusion, more studies should be accomplished specifically randomized controlled studies. Periodontal health Five studies were included in this literature reviewed evaluating periodontal health. One study concluded the plaque formation was similar in Invisalign and Fixed Appliance groups but that gingival health was worse in the Fixed Appliance group. A second study concluded that the plaque formation was significantly lower for the Invisalign group in comparison to the fixed appliance group but that periodontal health was not statistically different. A third study concluded that periodontal health was significantly better in the Invisalign group than the orthodontic appliance group. There were significant potential biases and methodological limitations in these studies previously mentioned that lead to a cautious acceptance of the results. Specifically, group demographics, variance in oral hygiene between groups, use of single examiners, and absence of blinding could 20 Orthodontic practice

be problematic to assume a high level of evidence is supported by these studies. A systematic review was included in this literature review. Five studies were included of the 1,247 that met search criteria. The conclusion of the systematic review was that periodontal health was significantly better in the clear aligner group compared to the fixed appliance group. The authors of the systematic review acknowledged that “most of the studies presented with methodological problems: bias and confounding variables, lack of adequate blinding procedures and absence of proper randomization methods. Thus, conclusions with a moderate level of evidence could be drawn from the review process.” A randomized control trial was included in this review that concluded there “was not enough evidence to reject the null hypothesis that the type of orthodontic appliance has no effect on periodontal health.” This study likely has the highest level of evidence of the included studies for this literature review. The two examiners were calibrated in this study but could not be blinded to types of treatment being performed which may allow for potential bias. In conclusion, there is conflicting evidence as to which type of orthodontic treatment, Invisalign versus fixed orthodontic appliances, demonstrates better periodontal health. Further randomized control studies are needed. We cannot accept nor reject the null hypothesis that there are no differences in periodontal health experienced by patients

who are orthodontically being treated with Invisalign as compared to traditional fixed appliances. Caries/Demineralization Six studies were included for evaluation of caries and demineralization susceptibility due to interproximal reduction during orthodontic treatment. One study had only a single subject, and therefore had no validity or statistical significance. The type of enamel removal and whether the enamel was polished after IPR had a significant impact on the outcome of caries and demineralization susceptibility. A 10-year study was included, which has the longevity and support to validate the null hypothesis. The remaining studies with statistical significance further clarify these results. Overall, the studies agree that demineralization can occur; however, with proper interproximal reduction, post-reduction polishing, and a fluoride treatment, the susceptibility of caries and demineralization are minimal to none. Therefore, the null hypothesis and the experimental hypothesis are supported.

Acknowledgments The authors would like to extend their appreciation to Dr. Harish Parihar (the biostatistician) and Dr. John Stockstill, Professor and Director of Dental Research at the Georgia School of Orthodontics, for their valuable guidance and contributions to this article. OP

REFERENCES 1. Miller K, McGorray S, Womack R, et al. A comparison of treatment impacts between Invisalign aligner and fixed appliance therapy during the first week of treatment. Am J Orthod Dentofacial Orthop. 2007;131(9):302. 2. Shalish M, Cooper-Kazaz R, IvgiI et al. Adult patients’ adjustability to orthodontic appliances. Part I: a comparison between Labial, Lingual, and Invisalign. Euro J Orthod. 2011;34(6):724-730. 3. Fujiyama K, Honjo T, Suzuki M, Matsuoka S, Deguchi T. Analysis of pain level in cases treated with Invisalign aligner: comparison with fixed edgewise appliance therapy. Prog Orthod. 2014;15(1):64. 4. White D, Julien K, Jacob H, Campbell P, Buschang P. Discomfort associated with Invisalign and traditional brackets: A randomized, prospective trial. Angle Orthod. 2017;87(6):801-808. 5. Azaripour A, Weusmann J, Mahmoodi B, et al. Braces versus Invisalign®: gingival parameters and patients’ satisfaction during treatment: a cross-sectional study. BMC Oral Health. 2015;15:69. 6. Miethke R, Brauner K. A comparison of the periodontal health of patients during treatment with the Invisalign system and with fixed lingual appliances. J Orofac Orthop. 2007;68(3):223-231. 7. Rossini G, Parrini S, Castroflorio T, Deregibus A, Debernardi C. Periodontal health during clear aligners treatment: a systematic review. Eur J Orthod. 2014;37(5):539-543. 8. Low B, Lee W, Seneviratne C, Samaranayake L, Hagg U. Ultrastructure and morphology of biofilms on thermoplastic orthodontic appliances in ‘fast’ and ‘slow’ plaque formers. Eur J Orthod. 2010;33(5):577-583. 9. Levrini L, Mangano A, Montanari P, et al. Periodontal health status in patients treated with the Invisalign system and fixed orthodontic appliances: A 3 months clinical and microbiological evaluation. Eur J Dent. 9(30);404-410. 10. Chibber A, Agarwal S, Yadav S, Kuo C, Upadhyay M. Which orthodontic appliance is best for oral hygiene? A randomized clinical trial. Am J Orthod Dentofacial Orthop. 2018;153(2):175-183. 11. Birdsall, J and Robinson, S. A case of severe caries and demineralization in a patient wearing an essix-type retainer. Prim Dent Care 15(2);59-61. 12. Zachrisson B, Minster L, Øgaard B, Birkhed D. Dental health assessed after interproximal enamel reduction: Caries risk in posterior teeth. Am J Orthod Dentofacial Orthop. 2011;139(1):90-98. 13. Jarjoura K, Gagnon G, Nieberg L. Caries risk after interproximal enamel reduction. Am J Orthod Dentofacial Orthop. 2006;130(1):26-30. 14. Zachrisson B, Nyøygaard L, Mobarak K. Dental health assessed more than 10 years after interproximal enamel reduction of mandibular anterior teeth. Am J Orthod Dentofacial Orthop. 2007;131(2):162-169. 15. Meredith L, Farella M, Lowrey S, Cannon R, Mei L. Atomic force microscopy analysis of enamel nanotopography after interproximal reduction. Am J Orthod Dentofacial Orthop. 2017;151(4):750-757. 16. Twesme D, Firestone A, Heaven T, Feagin F, Jacobson A. Air-rotor stripping and enamel demineralization in vitro. Am J Orthod Dentofacial Orthop. 1994;105(2):142-152.

Volume 12 Number 2

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Evaluation of adverse physiological events during Invisalign® treatment: part 2 BROOKS, ET AL.

1. (Regarding the Miller K, McGorray S, Womack R, et al., comparison) Overall, Invisalign patients reported less of a quality-of-life decrease during the first week of treatment, and fixed appliance patients reported _______. a. more analgesic use b. no analgesic use c. no quality-of-life decrease d. quality-of-life increase 2. (In the Shalish M, Cooper-Kazaz R, IvgiI I, et al., comparison) Overall, ______ were associated with the worst perceived pain and oral disturbances. a. clear aligners b. buccal appliances c. lingual appliances d. both a and b 3. In the randomized prospective trial by White D, Julien K, Jacob H, Campbell P, and Buschang P, it was found that overall, Invisalign may offer less pain in comparison to traditional orthodontic appliances specifically after adjustments. The intensity of pain appeared to ________ over time after the 2-month time frame. a. increase b. decrease c. stay the same d. interfere with quality of life 4. (In the Azaripour A, Weusmann J, Mahmoodi B, et al., cross-sectional study) The findings suggest Invisalign and fixed

Volume 12 Number 2

appliances have similar plaque measurements, but that fixed appliances demonstrated a ________. a. better gingival condition b. worse gingival condition c. reduced need for analgesics d. reduced need for focus on hygiene 5. (In the Levrini L, Mangano A, Montanari P, et al., clinical and microbiological evaluation) The Invisalign® group showed better results in terms of ________ compared to the fixed orthodontic appliance group. a. periodontal health b. total biofilm mass c. pain perception d. both a and b 6. (From the case study by Birdsall J and Robinson S, the authors noted) It is of extreme importance that the patient be informed of proper wear and care instructions for _______. a. lingual braces only b. all Essix-type retainers as well as clear aligners c. buccal braces only d. younger patients only 7. (In the Zachrisson B, Nyøygaard L, Mobarak K, study) The study found that no carious lesions were noted, no evidence of root pathology, the distance between roots was _______ in patients who had stripping of the anterior teeth, and 59 of the patients

experienced no sensitivity with temperature differences. a. significantly less b. significantly greater c. the same d. negligible 8. (According to the authors, for the Meredith L, Farella M, Lowrey S, Cannon R, Mei L, analysis) Teeth can vary even within a subject and have multifactorial items to be considered such as _______, and nutritional resultant wear. a. oral hygiene b. enamel wear c. age d. all of the above 9. (In the Twesme D, Firestone A, Heaven T, Feagin F, Jacobson A, study) Each abraded surface of all time frames resulted in a greater depth of demineralization and ____. a. less mineral density b. decreased sensitivity c. no caries at all d. no gingivitis at all 10. (In the caries/demineralization summary) Overall, the studies agree that demineralization can occur; however, with _______ the susceptibility of caries and demineralization are minimal to none. a. proper interproximal reduction b. post-reduction polishing c. a fluoride treatment d. all of the above

Orthodontic practice 21

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

A comparison of digital-based treatments — Invisalign® versus LightForce® Dr. David Alpan shares his expertise with two digital tooth-moving technologies Abstract I thought it would be interesting to do a retrospective comparison6 of two different digital-based treatment outcomes with patients who presented with similar malocclusions, treatment time, age, and a desire for similar outcomes. This article will focus on two digital-based treatment systems while looking at two different patients — one treated with Invisalign® and the other treated with LightForce® braces. Both patients were given vibration devices to accelerate treatment and reduce discomfort. Digital-based treatments start with an initial digital 3D scan. We use the iTero® system by Invisalign/ Cadent to capture our images. Invisalign and LightForce systems require a digital submission; although Invisalign will still accept PVS impressions, it is not recommended. LightForce will only accept digital scans based on numerous studies. Showing an initial 3D intraoral scan is more precise then PVS systems, especially because the PVS impressions have to be scanned. This extra step introduces more errors than a direct intraoral scan. We also prescribe i-CAT 3D X-rays to view ceph, pano, airway, and TMJ images. The initial submission process is very similar, but the compliance required to achieve the desired outcome is dramatically different. Each system offers its benefits to patients, and the results can be almost identical, but the underlying difference between a clear removable aligner and fixed braces is assessing the patient’s compliance level. Great compliance will always lead to better

Educational aims and objectives

This self-instructional course for dentists aims to show the benefits of two digital toothmoving technologies — Invisalign® and LightForce® — for patients with different compliance levels.

Expected outcomes

Identify characteristics of Invisalign technology.

•

Identify characteristics of LightForce technology.

•

Realize some shortcomings of traditional, non-digital treatment planning.

•

Observe the case of a previously noncompliant patient who needed braces.

•

Observe the case of a previously treated patient who was compliant and received clear aligners.

treatment outcomes, but what if the patient is not compliant? I will show that we can we still achieve excellent results with a digital-based fixed bracket system in a less or noncompliant patient.

Introduction Invisalign is a series of removable clear aligners completely customized to each patient’s specific needs. Yet aligner therapy requires compliance to achieve the desired tooth movements in a reliable way.5 Attachments are utilized with aligners to improve the control and reliability of the outcomes. Attachments function by increasing the surface area and creating a lever, so the plastic can apply the force required to move the teeth very much like a bracket. Adjuncts are utilized in conjunction with aligners to achieve many of the more difficult desired

David Alpan, DDS, MSD, earned his dental degree in 1996 and completed his orthodontic specialty certificate from University of the Pacific Arthur Dugoni School of Dentistry in 1998. He was awarded a MSD after writing his Master’s thesis on the results of a TMJ research project. Dr. Alpan currently treats patients out of four private practice locations: Los Angeles, Century City, Woodland Hills, and Hawthorne, California. He has lectured for Invisalign® from 1992-1998 at over 250 locations to over 10,000 doctors. He played an integral part of implementing the Invisalign system into the Dental School curriculum. Alpan was an Ormco™ insider and helped 3M™ as a research panelist for many years. Alpan is a key opinion leader for AcceleDent and Propel and has published several articles on accelerated orthodontics. As a Center of Excellence member for Incognito™ and a high-volume Insignia™ provider, he has incorporated several digital-based systems with custom brackets and wires into his digital workflow. Dr. Alpan is currently treating all his patients with Invisalign or LightForce® digital-based systems with airway and TMJ in mind. He is an active member of ADA, CDA, LADS, PCSO, AAO, CAO, AO, OKU, and TKO. His hobbies are racing cars, as a member of Pirelli cup NASA, POC, PCA, CSM, and BMW CCA. He is also a competitive shooter with NSSA, USPSA, UPL, and IDPA, and spends his free time with his family. Disclosure: Dr. Alpan did not receive financial compensation for any of the products mentioned in this article, but he is a key opinion leader for LightForce®.

22 Orthodontic practice

results that aligners alone are not able to accomplish. There are many systems to create adjuncts to overcome the limitations of aligners and, in combination, can treat any malocclusion. I routinely use aligners with TADs and vibration to treat orthognathic surgical patients in 18 months, reducing overall treatment by 6 to 12 months in comparison to a worldwide average of 22 to 26 months.2,3,4 LightForce Orthodontics creates a fixed bracket system that is completely customized based on the desired movements, so torque, tip, and angulations are programmed into the bracket for full control in three dimensions of space. The 3D-printed base on the bracket eliminates the need for custom wires. It is truly a straight-wire technique with the goal to completely remove the need to bend wires. I personally don’t mind bending wire, but the patients and my team have expressed issues about that part of the process. Detailing wires takes up doctor chair time, and the patients usually have more sensitivity at this stage of treatment. The introduction of prescription brackets and nickel-titanium wires were some of the first techniques introduced to reduce wire bending; then as composite material improved, repositioning brackets became another way to reduce wire bending. With a fully custom bracket, the fundamental goal is to eliminate the wire bending and reduce Volume 12 Number 2

my treatment and if utilized properly can save overall treatment time and visits to the office. There are some limitations on devising final treatment planning details clinically compared to using 3D digital models. It is difficult to see as much or as well as you can on a model compared to clinically where there is a tongue, cheeks, and a personality to help determine the plan. The efficiency of incorporating digital treatment planning to orthognathic surgical cases has proven to reduce treatment time by 6-12 months.1 Coordination of arches prior to surgery is much easier and effective with digital treatment planning then traditional orthodontic bracket systems. We do not submit 3D X-rays to either Invisalign or LightForce at this time, but we hope to integrate this data in the future. During 3D digital planning, I presume we will be able to verify root position, morphology, torque, tip and angulations, prognosis of roots, and other valuable information. My experience has been that with more data, we can hope to plan for specific force vectors with these custom appliances to achieve more ideal finishes with fewer case refinements and/or details to our finishing archwires.

I chose two patients with similar diagnosis and treatment plans. Both of my patients presented in their late 20s with a desire to widen and improve their smiles. We scanned both patients with iTero and submitted the digital images as well as a standard set of photos, ceph, and pano with the prescription form submitted online. The 3D setup was created from my prescription, and refined through modifications until I was happy with the final set up (Figure 25). The digital interface gives me the ability to analyze the final outcome prior to ever treating the patient. I am also able to create more than one treatment outcome and evaluate multiple treatment options without ever touching the patient. As an example, I can set up an extraction versus non-extraction set up, or a single mandibular incisor extraction setup to see how much IPR will be needed in the maxillary arch. All my treatment planning can be verified with the 3D digital setup. Both Invisalign and LightForce provide a 3D digital rendition of the final outcome that can be manipulated by the clinician until satisfaction with the final result is achieved (Figures 11 and 25). Once I accept the digital setup (Figures 11 and 25), I receive my appliances 4 to 5 weeks after submission. I follow the series of aligners just as I would if I were changing archwires. The big difference with my digital planning is I am not doing a midtreatment progress pano to evaluate the roots and planning to reposition brackets. All my planning is done in the digital stage, so I am not left to guessing during treatment. The only time I am not able to do this is when a tooth is impacted or blocked out, and I have to rescan after the tooth is accessible.

Patient No. 1 — CC Figure 1: CC Initial images

Figure 3: CC Initial pano Volume 12 Number 2

Figure 2: CC Initial ceph

Patient No. 1, CC, had attempted to use Invisalign twice prior, once with a dentist and

Figure 4: CC Progress images Los Angeles Lakers colors Orthodontic practice 23

CONTINUING EDUCATION

overall treatment time. Efficiency is always our goal in orthodontics, and eliminating repositioning of brackets and bending wires will reduce treatment time in every fixed bracket case. I still find myself doing detail bends as my ability to get the 3D image just as I would in the mouth is still not as detailed as I prefer. Both systems are founded on a platform that begins with the end in mind with a final 3D tooth setup of all the teeth, including the bite. The 3D interface can display the before and after with the contact points visible or the amount of IPR needed. Digital-based treatment planning is far superior to the traditional “wait-and-see” to adjust systems. With traditional systems, the clinician needs to be prepared to make necessary multiple decisions mid-treatment. I was trained with edgewise brackets with a straight wire philosophy and have moved away from traditional bracket systems as I moved into the digital world. Clinically, placing brackets with indirect bonding has proven to be more accurate than just using my eyes. Using a custom fabricated tray or jig system can insure a higher level of accuracy and precision in

CONTINUING EDUCATION

Figure 5: CC Progress images July 4th colors

Figure 6: CC Final images

Figure 7: CC 6-month retention images

Figure 9: CC Initial arches images

Figure 8: CC Final ceph

once with an orthodontist. Both times she didn’t progress past the first few aligners. She had excuses for why the aligners did not work, but after discussing her compliance, there was no question removable aligners would never achieve the treatment goals based on her lack of compliance. I indicated I would not treat her with Invisalign and explained that LightForce braces would achieve her goals in 6 to 12 months. She was not happy about wearing braces as a young, attractive woman in her mid-20s, but agreed based on her lack of success due to noncompliance with removable aligners. Our experience with LightForce was that the custom bases of the brackets fit the contour of the tooth so well that we had no broken

Figure 11: CC Digital setup LightForce 24 Orthodontic practice

Figure 10: CC After arches images

brackets due to increased bond strength of a 3D-printed custom bracket base. No broken brackets helped reduce treatment time and improve the experience for the patient (Figures 1-10). When the bracket duplicates the morphology of the tooth, there is less reliance on the adhesive and, therefore, a stronger bond.

Figure 12: CC Rx data chart on each tooth movement Volume 12 Number 2

Patient No. 2, HA, had been treated with braces as a teenager but stopped wearing her retainers and noticed relapse in her early 20s. Her goal to widen her smile was related

to her profession as an actress. She wanted to achieve the result without interfering with her career. I offered her Invisalign treatment that would take 6 to 12 months, explained the compliance needed, and she agreed. If she

was not compliant with her aligners, I would have transferred her to braces. I have patients sign a compliance agreement that acknowledges that if they fail with aligners, we will succeed with braces. With a high level of motivation and a persistent desire to be compliant, she achieved her result without the use of braces or any adjuncts (Figures 13-24). After the completion of her treatment, we highly recommended a fixed retainer. Based on her past history with her retainer, we wanted some more “insurance” against relapse — that she would not need retreatment a third time.

Results

Figure 13: HA Initial images

Both patients ended up with a nice broad smile, aligned midlines, resolution of crowding, spacing, rotations of teeth, improved overbite and overjet in a similar

Figure 14: HA Initial ceph

Figure 15: HA Initial pano

Figure 17: HA Progress Invisalign

Figure 20: HA Initial arches Volume 12 Number 2

Figure 16: HA Initial TMJ series

Figure 18: HA Case refinement

Figure 19: HA Final images

Figure 21: HA Final arches Orthodontic practice 25

CONTINUING EDUCATION

Patient No. 2 — HA

CONTINUING EDUCATION

Figure 22: HA Final ceph

Figure 23: HA Final pano

Figure 26: HA Rx data chart on each tooth movement

expansion than Invisalign in less treatment time. There are many similarities in the treatment sequence, as you can see in the figures and in the appointment comparison chart below (Table 1). The exact tooth movement is in the Rx data charts (Figure 26).

Figure 24

Conclusion

Figure 25: Invisalign initial digital setup

number of visits to the office with two different digital-based orthodontic treatments. LightForce completed the treatment in 8 months, and Invisalign in 10.5 months. I don’t think the results are dramatically different, but the LightForce treatment created more arch

Invisalign and LightForce braces treatments created resolution of crowding, rotations, spaces, increased arch width, aligned midlines, and improved overbite and overjet. Both patients were completed in less than 1 year with the use of digital treatment planning and acceleration (vibration). After careful inspection, fixed appliances were able to achieve more arch expansion then clear aligners in a similar treatment time (Figures 9 and 10 versus Figures 20 and 21). I don’t

think Invisalign or LightForce is better than the other, but I think one is more suited for the noncompliant patient and the other is not. When a patient asks me which digital-based treatment appliance is better, I inform them one is for compliant, disciplined, organized, and responsible patients, and the other is for noncompliant patients. I can achieve the same results with both digital-based systems in less time and with less sensitivity then traditional non-digital brackets systems. Adding digital treatment planning with acceleration has reduced overall treatment time and number of visits to the office and has lead to more efficiency and overall increased capacity. I choose the digital treatment plan based on the patient’s compliance level and the desire to have treatment be as clear and unnoticeable as possible. OP REFERENCES

Table 1: Listing the appointments as a comparison CC — LightForce braces — 8 months of treatment (Figures 1-10)

HA — Invisalign 10.5 months of treatment (Figures 13-24)

1. Initial Records & Exam

10/24/2019

1. Initial records and exam

02/08/2017

2. Initial DB Mx LF braces 0.014nt

01/04/2020

2. Initial delivery of aligners

03/08/2017

3. DB Mn LF braces

0.014nt

01/24/2020

3. DB attach and IPR, deliver aligners

03/21/2017

4. Change Aw’s

0.016nt

02/08/2020

4. IPR and deliver Aligners

04/26/2017

5. Change Aw’s

0.018nt

02/19/2020

5. Deliver aligners

06/01/2017

6. Change Aw’s

14x25nt

03/05/2020

6. Deliver aligners

07/19/2017

7. Change Aw’s

18x25nt

04/02/2020

7. Deliver final aligners

09/08/2017

8. Change Aw’s & DB 7’s 18x25nt

05/13/2020

8. Evaluation for CR rescan Itero

09/27/2017

06/05/2020

9. Change Aw’s

21x25nt/17x25ss

9. Deliver CR Aligners

10/18/2017

10. Change Aw’s

19x25TMA/17x25ss 06/17/2020

10. Deliver Aligners

11/15/2017

11. Detail Aw’s

19x25TMA/17x25ss 06/25/2020

11. Deliver Aligners

12/14/2017

12. Detail Aw’s

19x25TMA/17x25ss 07/23/2020

12. Deband and Deliver rets

01/11/2018

13. DB fixed retainers deliverel retainers

01/18/2018

13. Deband Braces Adj bite & Del Rets

26 Orthodontic practice

08/12/2020

1. Paunonen J, Helminem M, Peltomaki T. Duration of Orthognathic-Surgical Treatment. Acta Odontol Scand. 2017;75(5):372-375. 2. Luther F, Morris DO, Karnezi K. Orthodontic treatment following orthognathic surgery: how long does it take and why? A retrospective study. J Oral Maxillofac Surg. 2007;65(10):1969-1976. 3. Dowling PA, Espeland L, Krogstad O, Stenvik A, Kelly A. Duration of orthodontic treatment involving orthognathic surgery. Int J Adult Orthod Orthognath Surg. 1999;14(2):146-52. 4. Slavnic S, Marcusson A. Duration of orthodontic treatment in conjunction with orthognathic surgery. Swed Dent J. 2010;34(3):159-66. 5. Rossini G, Parrini S, Castroflorio T, Andrea Deregibus A, Debernardi CL. Efficacy of clear aligners in controlling orthodontic tooth movement: A systematic review. Angle Orthod. 2015:85(5):881-889. 6. Alpan D. A review of accelerated orthodontics. Orthodontic Practice US. 2017;7(5)28-32.

Volume 12 Number 2

A comparison of digital-based treatments — Invisalign® versus LightForce® ALPAN

1. Aligner therapy requires ________ to achieve the desired tooth movements in a reliable way. a. compliance b. brackets c. detailing wires d. a drawn-out treatment time 2. (This author) routinely uses aligners with TADs and vibration to treat orthognathic surgical patients in _______. a. 6 months b. 10 months c. 18 months d. 24 months 3. LightForce Orthodontics creates a fixed bracket system that has a completely customized based on the desired movements, so _______ is/are programmed into the bracket for full control in three dimensions of space. a. torque b. tip c. angulations d. all of the above

a. increases b. eliminates c. underscores d. requires 5. The efficiency of incorporating digital treatment planning to orthognathic surgical cases has proven to reduce treatment time by ______. a. 2-4 months b. 6-12 months c. 14-16 months d. 2 years 6. _______ provide(s) a 3D digital rendition of the final outcome that can be manipulated by the clinician until satisfaction with the final result is achieved. a. Invisalign b. LightForce c. iTero d. both a and b 7. The author’s experience with LightForce was that patients had no broken brackets due to increased bond

4. (With the LightForce system) The 3Dprinted base on the bracket _______ the need for custom wires.

Volume 12 Number 2

c. light cure adhesive d. special silicate bonding cement

strength of a _______. a. 3D-printed custom bracket base b. low viscosity adhesive

8. Invisalign and LightForce braces treatments created resolution of crowding, _______, aligned midlines, and improved overbite and overjet. a. rotations b. spaces c. increased arch width d. all of the above 9. (In this article) Both patients were completed in _______ with the use of digital treatment planning and acceleration (vibration). a. exactly 4 months b. less than a year c. 14 months d. 18 months 10. After careful inspection, fixed appliances _______ than clear aligners in a similar treatment time. a. were able to achieve more arch expansion b. achieved less arch expansion c. were able to achieve equal amounts of arch expansion d. were less effective

Orthodontic practice 27

CE CREDITS

ORTHODONTIC PRACTICE CE

PRACTICE DEVELOPMENT

Increase clear aligner compliance, results, and patient trust Dr. Diane Milberg discusses achieving compliance through making the right choices

n the field of esthetic orthodontics, helping patients make educated decisions regarding their treatment is essential. So many patients come through my door with a preconceived notion of what they want when a different esthetic treatment would better suit their clinical needs as well as their lifestyle. The big push in our practice, plus one of our biggest differentiators, is that we spend significant time communicating with patients in order to understand their goals for treatment while also effectively building trusting relationships with patients. While I can provide a thorough treatment plan for my patient, it’s only beneficial if the patient follows the steps precisely; therefore, compliance is a pivotal part of a treatment plan. Whether I’m using traditional brackets or clear aligners, I’m here to help patients achieve their goals and provide expertise to ensure they end up with the smile they want and need.

Uncovering the lifestyle Discussing a patient’s lifestyle early in the process helps us determine together what treatment plan would be the best fit. We also work jointly to create a wish list of how they would like to look during treatment and afterward. Generally, I have a list of questions that I walk through with the patient to determine the best course of action, including: • What would you like to change? • Have you had orthodontic treatment before? If so, how did that process go for you? Diane Milberg, DDS, MSD, is an orthodontist at Milberg Orthodontics located in San Diego, California. Dr. Milberg received her undergraduate degree from the University of California at Los Angeles, her Doctorate of Dental Surgery at the University of California at Los Angeles School of Dentistry, and her Master’s degree at the University of Washington, Seattle. Dr. Milberg is a proud member of the Edward H. Angle Society of Orthodontists and is a Diplomate of the American Board of Orthodontics. Disclosure: Dr. Diane Milberg is a key opinion leader for 3M™.

28 Orthodontic practice

• Are you willing to wear rubber bands or have teeth extracted if needed? • What is the time frame you would like to be finished with treatment? • What do you do for work? Discussing what a patient does for work may not seem like the most important question for orthodontists and patients during this initial intake meeting. However, it’s quite important when it comes to compliance. Many of my patients, both adults and adolescents, are in the media or spend time in front of a camera and would prefer the most discreet treatment option possible. Factoring in this lifestyle component can help us decide what makes the most sense for treatment without interfering in patients’ day-to-day lives and, in turn, ensure that they’re more likely to follow the treatment plan more closely. Flexibility is a key need for many of my patients during their treatment. Obviously, that flexibility needs to fit within the confines of the treatment itself, but knowing these potential lifestyle or work-related needs can help determine specific next steps. Throughout the entire duration of the treatment, I work with my patients to better understand what curveballs may emerge and impact the plan. For example, if a patient

has a professional conference coming up, I will stress the importance of wearing aligners to bed and will recommend we hold off on changing them before the event for maximum comfort. This flexibility to meld to the patient’s routine makes clear aligners a popular esthetic choice in my practice.

Setting expectations; explaining limitations Are you looking for “better” or “perfect?” While I always want to strive for perfect, sometimes that isn’t always possible for a patient if compliance is a challenge. By asking this question up front, I’ve found that we can effectively discuss patients’ potential challenges with aligner compliance, and even determine if the level of incompliance means they are better suited for a different esthetic treatment. Explaining that clear aligners have limitations and setting a level of expectations of the results is a crucial conversation that I have up front with all patients that request clear aligners — and really any treatment option in general. Several years ago a patient came to our office for a second opinion, concerned that his teeth were not perfectly straight after using aligners from another orthodontist. Volume 12 Number 2

refinements. For example, when I tell patients that it is very important to wear aligners 22 hours a day, this means 22 hours a day.

that the products you use get the job done while matching their esthetic needs and expectations.

Understanding the unpredictability

Results are paramount

Like many orthodontists, I’m a bit of a control freak; I want each step and mechanism to work exactly as I planned. I initially waited a few years before integrating aligners into my practice because I wanted to ensure that whatever products I implemented produced the best possible results. By ensuring the products I used were going to help me transform smiles and help patients achieve the best-looking result possible and thoroughly communicating with patients throughout their entire treatment, I’ve been able to set up a solid base for my patients and treatment plans. My clear aligner system of choice is 3M™ Clarity™ Aligners as they are more optically clear than other products I’ve seen, and the attachments are more esthetic in shape and size while being easier to place. When patients are already concerned with appearance during treatment, it’s essential

Esthetic orthodontic solutions are a wonderful option we can offer our patients. Through these solutions, we’re able to provide them the freedom to look how they want and maintain their confidence and appearance during treatment. However, communicating with patients and setting expectations to ensure compliance are essential. By choosing products that work best for my patients’ needs and establishing a meaningful dialogue, I’m able to give them the smile they’ve wanted their whole life — that opportunity is an absolute privilege. I encourage all orthodontists to review how they communicate with their patients and incorporate real changes to set expectations and ensure compliance throughout patients’ entire treatment. Through this communication, you will be able to ensure esthetic and effective treatment plans more easily for all patients. OP

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Orthodontic practice 29

PRACTICE DEVELOPMENT

After listening to him and explaining the limitations of aligners, I asked him to return to the other orthodontist to discuss his concerns. When I spoke with the other orthodontist to tell him about his patient’s visit and his concerns, the orthodontist mentioned that he had not reviewed the limitations of aligners with his patient and would review refinements and other treatment options with him. This example is just one reason why explaining a treatment in full detail is essential to a patient’s success and satisfaction. By skipping this step, orthodontists put themselves and their patient at a disadvantage. Beyond compliance, it is important for an orthodontist to discuss timing in detail with patients and explain that if additional refinements are needed along the way, treatment can take longer than anticipated. While that’s not an ideal situation, it can happen, and it can be a letdown for patients who are anxiously waiting for their “perfect smile.” During our initial conversation, I aim to be transparent with timing expectations and stress the importance of compliance as incompliance can result in the need for

PRODUCT PROFILE

Allesee Orthodontic Appliances (AOA) The latest retainer technology for your practice

or more than 3 years, Allesee Orthodontic Appliances (AOA) has had the privilege to be partnered with CA DIGITAL, a highly technological company based in Germany, distributing a retention product called Memotain®. Memotain is a fixed lingual retainer that is bonded to either the upper or lower teeth. Each Memotain wire is custom-made to fit each patient’s unique tooth contours. The use of computer-aided design (CAD/CAM) fabrication allows the design of smaller, more intimate wires that offer a closer adaptation to the tooth surface. This reduces the number of contact points on each tooth and is designed to increase patient comfort and helps create optimal oral hygiene. The CAD/CAM and manufacturing process help control the optimal placement and a contoured fit. Memotain is manufactured using the shape-memory alloy nitinol, which makes Memotain much thinner and more comfortable to wear. The memory-based metal also helps it maintain its shape integrity, and the transfer tray makes delivery fast and predictable. Once the retainer is cut from the sheet of metal, the innovative material is difficult to bend. Each wire is electro-polished creating a smooth finish and helps minimize plaque and bacterial buildup. Memotain’s improved process and design can help the accuracy of fit with an approximate breakage rate of 1%*. In November 2020, AOA released the latest version of Memotain — Memotain 2.0. Added features such as selective smoothing of the interdental area help create a more exact positioning on the teeth. With this feature, you may also notice smoother interproximal bends. The new design also has partial retention elements to adhere to the bonding site. There are also other subtle features that were added to the software, designed to enhance the product.

The process of a case design 1. Models are put into occlusion. 2. Models are rotated to look at the lingual. 30 Orthodontic practice

Memotain 2.0 lingual retainers

“No longer do I have to bend wires, modify teeth, or worry if the retainer is going to fit.” — Dr. Bryan Green 3. A single arch is isolated. 4. Select wire location and place in occlusion, looking for interference. 5. After ensuring proper placement, shape the wire to various contact points. 6. Isolate single arch again to review positioning. 7. Rotate to occlusal view to look at the detail of the design. 8. Review final position before sending to CA DIGITAL for cut and polish.

To order Memotain 2.0 • Memotain cases can be submitted via scan, plaster, or stone models. • If upper or upper and lower Memotain are requested, we will need to have both individual arches. If scanned, scan in occlusion. • For lower cases only, we need only the lower.

• All scans just need to include one tooth distal of the Memotain coverage — i.e., lower 3-3 needs scan of 4-4. • Rx needs to be completed and sent to AOA along with the patient scan. (individual scanner portal, digital. services@aoalab.com.) • Lead time is approximately 2 to 3 weeks. AOA and CA DIGITAL continue to work in tandem to deliver a high-quality product while meeting your patients’ needs. For more information, contact your AOA/Ormco™ representative or customer care at 800-262-5221. Memotain® is a registered trademark from CA DIGITAL GmbH. OP

Source: CA DIGITAL statistical data (data sample) 30,000 retainers

This information was provided by Allesee Orthodontic Appliances (AOA).

Volume 12 Number 2

The Latest Retainer Technology for Your Practice!

INTRODUCING MEMOTAIN® 2.0 MEMOTAIN’S improved process and design can help the accuracy of fit with an approximate breakage rate of 1%*. Added features such as selective smoothing of the interdental area help create a more exact positioning on the teeth. With this feature you may notice smoother interproximal bends. The new design also has partial retention elements to adhere to the bonding site.

Contact your AOA/Ormco Representative for more information or Customer Care at 800.262.5221.

Memotain® is a registered trademark from CA DIGITAL GmbH * Source: CA Digital statistical data (data sample) 30,000 retainers.

M ®

S1156-P Rev A

TECHNOLOGY

Treatment of a Class II malocclusion with a TruEase™ fixed bite corrector: case report Drs. Emad Hussein, Sari Amer, Khaled Qatawi, and Yazan Ashhab discuss a non-extraction option that overcomes compliance problems Introduction International epidemiologic studies suggest that there seems to be over 25% prevalence of Class II malocclusions.1-5 However, the number of patients attending our clinics with Class II malocclusion features appear to be higher than the numbers in the epidemiologic studies. Class II malocclusion can be due to mandibular deficiency, maxillary excess, or a combination of both. McNamara, et al., found that the mandibular deficiency is more common than maxillary excess.6 Class II malocclusion could be also be due to dentoalveolar reasons — e.g., proclined upper incisors and/or retroclined lower incisors. In general, there are three treatment modalities to treat the Class II malocclusion: • First, if the patient is young and still growing, then growth modification in order to restrain the maxilla and to enhance growth of the mandible • Second, camouflage treatment by mainly retracting the upper segment, advancement of the lower segment, or both.

Besides his private practice in Ramallah, Professor Emad Hussein has been teaching orthodontics since 2003 at the Arab American University of Palestine until present. He established the department of orthodontics and the residency program of orthodontics at the Arab American University in Palestine where he became a full professor. Dr. Hussein also enrolled in the Palestinian medical council as an examiner in orthodontics from 2006 until September 2019. He also participated in the establishment of a cleft lip and palate society in Palestine. Dr. Hussein published several articles in international orthodontic and dental journals, including The Angle Orthodontist, American Cleft Lip and Palate Journal, World Journal of Orthodontics, Turkish Orthodontic Society Journal, and Saudi Dental Journal. He lectured on several orthodontic topics in the United States, United Kingdom, Cyprus, India, Turkey, Egypt, Dubai, Tunisia, Jordan, and Palestine. Sari Amer, Khaled Qatawi, and Yazan Ashhab are residents at the Arab American University in Ramallah. Disclosure: Dr. Hussein has not received financial remuneration for this article. He is the distributor for this Ortho Technology product in Palestine.

32 Orthodontic practice

• Third, orthodontic decompensation and orthognathic surgery in adults, keeping in mind that the treatment modality is dependent on a thorough diagnosis Growth modification appliances — e.g., removable functional appliances and headgear — require good cooperation from the patients, which in most cases considered an important factor in the success of treatment. The same applies to the use of Class II elastics, where the orthodontist has to time during every visit to convince the patient to wear them. Extractions in the treatment of Class II malocclusion sometimes are more successful after growth ceases, but many patients and their families refuse this treatment option. In order to keep the non-extraction option and, at the same time, to overcome the problem of compliance, bite correctors (also called fixed functional appliances) were introduced to the orthodontic armamentarium. Bite correctors are fixed orthodontic appliances attached to the upper and lower jaws that keep the lower jaw biting in an advanced position to centric occlusion but still can allow the mandibular condyle to go back to its original position in the glenoid fossa.

The TruEase™ bite corrector appliance design The True Ease™ bite corrector (Ortho Technology®) is a fixed push-type appliance clamped from both ends and bilaterally to the upper and lower archwires in each jaw (Figures 15-17). Each appliance is made of two parallel cylinders housing nickel-titanium coil springs. Each cylinder ends with a plunger that is incorporated into it. At the ends of both plungers are hex nuts, which attach the appliance to the archwires. In the upper arch, hex nuts are attached mesial to the upper molars, while in the lower arch, hex nuts are attached distal to the lower canines. Each bite corrector delivers a constant

pushing force on each side of approximately 200g, thus resisting the pulling forces of the muscles acting on the mandible.

Treatment protocol using TruEase bite corrector Fixed bite correctors are usually used after leveling and alignment procedures when reaching heavy stainless steel wire .019" × .025" in .022" brackets and .017" × .025" in .018" brackets (Figures 15-17). The purpose of reaching heavy steel wires before fixing the bite correctors is to overcome the side effects of the pushing forces delivered by the bite correctors, flaring of lower incisors, and lingual tipping of upper incisors. Each arch should act as a single unit; this is possible by a figure-eight ligature wire from first molar to the contralateral first molar, or a cinch-back distal to each molar or simply by the use of a power chain in order to avoid breakage of the tube during cinching back the heavy steel wires. Then if the overjet is reasonable, the bite corrector can be attached from each side of the mouth when the mandible is slightly closing edge-to-edge. If the overjet is large, then closing in a Class I molar and canine relationship could be satisfactory. TruEase bite corrector will show a remarkable correction of the Class II molar and canine relationship after 3 to 4 months of installation, but an additional 3 to 4 months are required to retain this correction and to overcome muscle tendency to pull back the mandible to a posterior location in the glenoid fossa. It is possible to notice an overcorrection and an edge-to-edge incisor relationship during this period; thus an 8-month period is necessary to induce the change and to retain it. And if overcorrection occurred, it is liable to relapse shortly after removal of the bite corrector to a normal overjet and overbite. After removal of the bite corrector, the case might require some finishing and detailing. In order to maximize the intercuspation, finishing bends and vertical buccal Volume 12 Number 2

Clinical case Examination and diagnosis A 12-year-old growing patient presented with the main complaint of protruded and crooked anterior teeth. She had a brachycephalic type of face with low lower anterior face height and competent lips. When smiling, she showed crowded and procumbent incisors. She presented with a convex soft tissue profile with retrognathic mandible and low lower anterior facial height (Figures 1-3). Intraorally, she had a good oral hygiene, 1 mm upper midline shifting to the left, and 50% overbite. She showed a Class II molar relationship as well as canine relationship on both sides; overjet was 7 mm (Figures 4-6). Her upper arch was ovoid and symmetric except in the incisor region where crowding shifted the midline 1 mm to the left side; crowding in the upper arch was around 4

mm. The lower arch was also ovoid and symmetric with 4 mm incisor crowding (Figures 7 and 8). In the orthopantomogram, all thirdmolar buds are present with lack of space for them to erupt; there were no pathological lesions and no significant root resorption. Her dental age coincided with chronological age (Figure 9). In the cephalometric analysis, the patient is skeletal Class II based on Wits analysis. All vertical readings indicate horizontal growth and a hypodivergant facial pattern with a decreased lower anterior facial height (Figure 10). Soft tissue shows normal upper lip with average nasolabial angle, while the lower lip is slightly retrusive. Dentally, upper incisors were in proclined and protruded position, while the lower incisors were proclined and in an average position (Figure 10). According to the Cervical Vertebral Maturation (CVM) Method described by

Baccetti In 2005,7 the patient was in cervical stage 3, concavities at the lower borders of both C2 and C3 were present, and the body of C3 was trapezoid in shape, which indicated that the peak of mandibular growth would occur during the year after this stage (Figure 11). Treatment goals Our main goal of starting treatment at this age for this growing patient was to enhance the growth of the mandible and restrain growth of the maxilla, thus improving facial esthetics. We also aimed to relieve crowding and retract the upper teeth to achieve average overjet and overbite. Treatment options The patient was still growing and using a growth modification appliance — e.g., a cervical headgear or a functional appliance was suggested to the patient and her mother, but they refused this option from compliance point of view.

Figures 1-3

Figures 4-6

Figures 7 and 8 Volume 12 Number 2

Figure 9 Orthodontic practice 33

TECHNOLOGY

elastics are mainly used to achieve the solid intercuspation. The solid intercuspation is an important factor in stability of the Class II correction. Due to the upward and backward forces acting on the upper molars, they might become intruded with a vertical distance with lower molars upon closure into maximum intercuspation; in some cases, cutting the archwires mesial to the molars may allow molars to erupt passively and freely until maximum interdigitation is reached. Retention of cases treated by a fixed functional appliance is by a lower fixed retainer from canine to canine in the lower arch. In the upper arch, retention is by a vacuum clear retainer or a Hawley retainer.

TECHNOLOGY Extractions of two upper first bicuspids was also suggested the patient, but she also refused this option. A fixed functional appliance with bite corrector along with a self-ligating bracket system was our third option for treating this patient with this skeletal and dental malocclusion, and the patient as well as her mother accepted this treatment option. Treatment progress A fixed orthodontic appliance of 022 028-inch self-ligating brackets Lotus DS (Ortho Technology) was bonded in the upper

Figures 10 and 11

and lower arches; .014-inch TruFlex™ copper nickel-titanium wires (Ortho Technology) were used for the leveling and alignment in the upper and lower arches for 6 weeks, followed by 018 copper nickel titanium for another 6 weeks (Figures 12-14). After using round wires used for alignment, .014 .025-inch copper nickel-titanium wires were used to continue the alignment and start preparation for torque. Six weeks later, .018 .025 copper nickel-titanium wires were used to continue leveling and alignment and torque control and to prepare for steel wires. Stainless steel .019 .025 inch wires were used in the upper and lower arches after 8 weeks of the use of .018 .025 copper nickel titanium. Four weeks after insertion of the steel wires, a fixed functional appliance, TruEase bite corrector from Ortho Technology, was installed on these heavy steel wires. In the upper arch, the bite corrector was screwed between the first molar and the second premolar; and in the lower arch, it was screwed between the canine and the first premolar (Figures 15-17).

The TruEase bite corrector was used for 10 months until the overjet was zero with reduced overbite to anticipate for relapse after removal. One month before appliance removal, archwires were cut mesial to the upper and lower first molars to allow their settling and better interdigitation. Treatment results Treatment resulted in a remarkable improvement in the face due to the continued and enhanced mandibular growth; thus the patient’s convexity has improved. The mentalis muscle strain has decreased due the improvement in the inter jaw relationship. The lower anterior face height was increased, but did not affect facial convexity. Occlusally, the results showed a Class I molar and canine relationship with normal overbite and overjet and good tooth interdigitation (Figures 18-25).

Discussion Treatment of Class II malocclusion by bite correctors was successful, although

Figures 12-14

Figures 15-17

Figures 18-20 34 Orthodontic practice

Volume 12 Number 2

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TECHNOLOGY

Figures 21 and 22

Figure 26

Figures 23-25

The use of bite correctors will shorten treatment time compared to removable functional appliances. most of the correction was a dentoalveolar type and more than a skeletal type. However, if treatment is carried out during the pubertal growth spurt, then the use of a fixed functional appliance can help mandibular growth potential to be expressed fully.8,9 The use of bite correctors will shorten treatment time compared to removable functional appliances, especially due to the fact that bite correctors are installed on the main archwires after leveling and alignment, so we don’t have to wait until the correction of the interarch relationship occurs and then bond the teeth by a fixed orthodontic appliance.10, 11 The forces produced by these bite correctors are similar to the forces produced by the application of a high-pull headgear on the maxilla, leading to intrusion and distalization of the upper molars, and intrusion and proclination of lower anterior teeth.12 The use of heavy archwires is important to overcome proclination of the lower anterior teeth. Torque control of the lower anterior teeth will also help to antagonize these side effects by applying a lingual crown torque in the lower anteriors or using brackets with a 36 Orthodontic practice

negative torque for lower incisors and a positive torque for the upper incisors.9,10 Bite correctors are contraindicated in Class II mandibular deficiency with severely proclined lower incisors, especially those with thin gingival biotype because further proclination is expected with the use of bite correctors despite the use of heavy archwires. Bite correctors work efficiently in low-tonormal angle cases, but there are no studies about their efficiency in high-angle cases. Probably, the intrusion of upper molars can prevent the increase in vertical dimension during orthodontic treatment, but still treating high-angle cases with bite correctors should be carried out with caution. Still bite correctors are preferred more than Class II elastics because they tend to produce less occlusal plane rotation than Class II elastics. However, patients with a favorable growth pattern and a low mandibular angle will show more treatment success, and better facial changes when treated with bite correctors.9, 13

Conclusions TruEase bite correctors managed to correct the Class II malocclusion by a

dentoalveolar movement in a non-extraction pattern, and this led to occlusal and skeletal improvement and facial harmony after treatment. The proper interdigitation of the teeth after the use of bite corrector will help in the long-term stability of the results. Keep in mind that stability depends on the severity of the original malocclusion. OP

REFERENCES 1. Horowitz HS, Doyle J. Occlusal relations in children born and reared in an optimally fluoridated community. Angle Orthod. 1970;40(3):104-111. 2. Trottman A, Elsbach HG. Comparison of malocclusion in preschool black and white children. Am J Orthod Dentofacial Orthop. 1996;110(1):69-72. 3. Lavelle CL. A study of multiracial malocclusions. Community Dent Oral Epidemiol. 1976;4(1):38-41. 4. El-Mangoury NH, Mostafa YA. Epidemiologic panorama of malocclusion. Angle Orthod. 1990;60(3):207-214. 5. Proffit WR, Fields HW, Sarver DM, Ackerman JL. Contemporary Orthodontics. 5th ed. Mosby Elsevier: St Louis, MO; 2013. 6. McNamara Jr, James A. Components of Class II malocclusion in children 8–10 years of age. Angle Orthod. 1981;51(3):177-202. 7. Baccetti T, Franchi L, Mcnamara JA Jr The Cervical Vertebral Maturation (CVM) Method for the Assessment of Optimal Treatment Timing in Dentofacial Orthopedics. Semin Orthod. 2005;11:119-129. 8. Kragt G, Duterloo HS. The initial effects of orthopedic forces: A study of alterations in the craniofacial complex of a macerated human skull owing to high-pull headgear traction. Am J Orthod Dentofacial Orthop. 1982;81(1):57-64. 9. Franchi L, Alvetro L, Giuntini V, et al. Effectiveness of comprehensive fixed appliance treatment used with the Forsus Fatigue Resistant Device in Class II patients. Angle Orthod. 2011;81(4):678-683. 10. Chibber A, Upadhyay M, Uribe F, Nanda R. Mechanism of Class II correction in prepubertal and postpubertal patients with Twin Force Bite Corrector. Angle Orthod. 2013;83(4):718-727. 11. Chhibber A, Upadhyay M, Uribe F, Nanda R. Long-term stability of Class II correction with the Twin Force Bite Corrector. J Clin Orthod. 2010;44(6):363-376. 12. LeCornu M, Cevidanes LH, Zhu H, et al. Three-dimensional treatment outcomes in Class II patients treated with the Herbst appliance: a pilot study. Amer J Orthod Dentofacial Orthop. 2013;144(6):818-830. 13. Franchi L, Baccetti T. Prediction of individual mandibular changes induced by functional jaw orthopedics followed by fixed appliances in Class II patients. Angle Orthod. 2006;76(6):950-954.

Volume 12 Number 2

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PRODUCT PROFILE

Running a digital practice without it running you Dr. David Defay discusses how switching to an in-office aligner software company saved him time and money while providing more creative freedom and versatility

fter 10 years in practice and a recent expansion to a second office in Utah, I knew it was important to further utilize technology, but I also didn’t want my digital practice to run my personal life. My goal was to have a fully digital workflow and have greater control over treatment to efficiently achieve the results that I wanted. My first step was to train members of my team to become digital technicians. I began to realize that having a remote third-party technician was not the most efficient approach to digital treatment planning. I researched a variety of approaches and selected uLab Systems as the software and company that would support me in this process.

Making the switch My decision to switch to uLab happened pretty quickly; it took about a month or two to decide between uLab and another software company. I was part of the initial beta pilot of uLab in 2017. Overall, I had a great experience with uLab’s support team; they were very helpful and responsive to our user feedback. The fact that the uLab software automatically segments teeth with artificial intelligence and uses your preferences to create a David Defay, DDS, MS, knew at age 11 that he wanted to pursue a career in orthodontics. He saw and felt the value of providing lasting, quality smiles to others while experiencing his own orthodontic treatment. Since that time, Dr. Defay completed his undergraduate education at Utah State University, majoring in Business Administration and minoring in Chemistry. He then received his specialty training at the University of Iowa Department of Orthodontics. At the completion of his residency, Dr. Defay earned a Specialty Certificate in Orthodontics and Dentofacial Orthopedics. At the University of Iowa, he also completed a Master’s thesis utilizing 3D photography to study the genetics of orofacial clefting, and after completing this research, Dr. Defay was awarded an MS in Orthodontics. He attended The Ohio State University College of Dentistry where he earned the Doctor of Dental Surgery degree. He has spent his professional and scholastic career dedicated to developing the best possible experience and providing outstanding results for his orthodontic patients. Dr. Defay loves being involved in the Utah community where he resides. He enjoys snow skiing, water sports, and cheering on the Utah Jazz basketball team with his wife and kids. Disclosure: Dr. Defay has no financial relationship with uLab.

38 Orthodontic practice

baseline treatment plan was particularly appealing. It was really powerful; just minutes after a scan, I could start moving teeth. By 2018, I felt that I could do any aligner case with uLab. I was comfortable treating with uLab and confident that I could transition all of our aligner cases to in-office. My practice was uDesign™ software uses AI Guided Setup to help create staging, sequencing, velocity, pontics, and more for moderate to complex cases growing, my aligner cases were growing, and the software and processes were capable. UnfortuGaining versatility and efficiency nately, I didn’t have the staff to produce all of uLab has given me creative freedom our aligners in-office. I had to make a decision and versatility. The software platform has — should I ramp up my in-office lab to support changed the way that I see detailing and the additional demand or begin outsourcing finishing cases, and how I look at options some aligner production? I worried hiring for difficult cases. additional staff to manage additional in-office I’m now finishing more cases with aligners aligner production could become a distraction instead of keeping braces on longer. This is to what I do best every day. a big benefit since it eliminates two appointFortunately, uLab came to the rescue. ments for the patient (and my office). I’m uLab had expanded its services to include also doing more hybrid cases. For example, a manufacturing facility in Tennessee. The I can now treat a patient with one arch of timing couldn’t have been more perfect. braces and one of aligners. I can also do a In December 2020, we began taking full few months of braces for an adult with difficult advantage of uLab’s aligner manufacturing movement and then shift to aligners. Hybrid capabilities. cases are no longer intimidating from a cost or process standpoint. I now feel like I have The best of both worlds every option available for treating my patients. Having the ability either to do aligners in-office or to send them out for manuSaving time and costs facturing really is the best of both worlds. Financially, if I had to compare my pracI love that I can turn around three-to-five tice now versus when we were all third-party, stage aligner cases in the same day with our I would estimate there is at least a 50% cost in-office processes yet send out a bigger savings — regardless of whether I make 20-arch case, upper and lower, to uLab’s aligners in-office or use uSmile Aligners out manufacturing facility. Having a choice of Memphis. And due to the development of helps remove the pressure of producing all my staff’s digital capabilities through uLab, of the aligners in my office. I’ve been really I personally spend at least 50% less time happy with the quality of aligners, packon cases. aging, 10-day delivery, and support. This uLab has given me the ability to tweak approach allows me to provide my patients and change my systems as my practice with better results, faster delivery times, and continues to grow. If you are looking for lower costs while only utilizing my existing the next step in digitizing treatment and staff, at the same time retaining the capaenhancing clear aligner treatment in your bility to print in-office when needed. practice, uLab is the best option. OP Volume 12 Number 2

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TECHNOLOGY PROFILE

The BRIUS System: independent tooth movement Introducing the first orthodontic system providing independent tooth movement Orthodontist/physicist who invented BRIUS Dr. Mehdi Peikar, DDS, PhD, the inventor of BRIUS, created BRIUS to fix many of the issues he faced with the patients he was treating — namely, poor esthetics, long treatment time, and painful frequent visits for adjustments. Using his background in biophysics, he devised a system that would provide the best biomechanics possible by utilizing recent advances in 3D printing, material science, and artificial intelligence. Dr. Peikar received his orthodontic degree from UCLA, his PhD from Johns Hopkins in Biophysics, and his Master’s degree in Quantum Mechanics from University of Illinois at Urbana-Champaign (UIUC).

Novel orthodontic system BRIUS, a new CAD/CAM orthodontic treatment system, allows orthodontists, for the first time, to move teeth independently. This lets the orthodontist move teeth from the initial to their final position with minimal round-tripping, which results in a more efficient treatment. Furthermore, one BRIUS is enough to complete mild to moderate cases. The BRIUS system (Figures 1 and 2) is a preprogrammed orthodontic system that uses only non-sliding mechanics, but does so via Independent Tooth Movement (ITM). The BRIUS system is made of shape memory NiTi. It consists of an anchorage base and

Dr. Mehdi Peikar, DDS, PhD, the inventor of BRIUS

flexible arms, which connect independently to each tooth. The stabilizing anchorage base is the backbone of the entire system and is designed to lie 0.5 mm from the patient’s palate or lingual vestibule. Using the anchorage base, modification of arch form (maintain, expand, or constrict), and occlusal plane (maintain, tip clockwise, or counterclockwise) becomes possible should it be desired due to the anchorage base’s ability to apply force by design. Based on the movement of a particular tooth, the proprietary BRIUS algorithm uses advanced mathematical techniques to choose the arm that applies the ideal force/moment to said tooth. Furthermore, the anchorage base and arms all have a smooth surface with no sharp edges for patient comfort. Additionally, there is no wire between adjacent teeth, which makes flossing much easier for the patient.

Low-profile brackets The BRIUS system can utilize any bracket system but currently uses the lowest profile bracket on the market, 2D® Lingual from Forestadent®. The unique connection

Figure 1: Independent Tooth Movement (ITM) 40 Orthodontic practice

Figure 2: BRIUS anchorage base and flexible arms made of shape memory NiTi

Figure 3: BRIUS particularly excels in expansion and deepbite cases. Above is a BRIUS patient with crossbite resolved after 12 months

between the BRIUS arm and 2D Forestadent bracket allows the BRIUS system to have complete control in all 6 degrees of freedom (3 translational and 3 rotational). The low profile leads to fewer debonds and also is significantly more comfortable for the patient. The process is as follows: 1. Orthodontist sends BRIUS the STL files, intraoral/extraoral photos, CBCT (suggested), and Treatment Plan instruction. 2. BRIUS provides the doctor with a 3D virtual treatment simulation that includes roots and the bone if a CBCT is submitted. 3. Upon approval from the doctor, BRIUS’s proprietary algorithm chooses which arm/spring will be selected for each tooth. 4. The BRIUS and digital bonding tray (DBT tray) and brackets will be manufactured and sent to the orthodontist in less than 2 weeks. 5. The orthodontist bonds the brackets with the DBT tray and places the BRIUS. 6. Upon completion of treatment, BRIUS will accept a final scan and manufacture retainers for the patient. OP This information was provided by BRIUS.

Volume 12 Number 2

Invisalign® G8 offers more predictable deep-bite correction and posterior arch expansion.

Introducing Invisalign G8 with SmartForce® Aligner Activation. Invisalign G8 is the only clear aligner system with the advantage of SmartForce aligner activation. This new generation of the Invisalign clear aligner system is designed to further enhance predictability and efficiently deliver improved clinical outcomes for the challenges you encounter most frequently. With SmartForce aligner activation, areas on the aligner surfaces are contoured to apply forces to the tooth in the proper direction to produce the desired movement while minimizing unwanted movements.

Discover more about the latest generation of the Invisalign clear aligner system. Visit Invisalign.com/G8.

For professional dental use only—Rx only. In rare cases, allergic reactions can occur. © 2021 Align Technology, Inc. All Rights Reserved. Invisalign, the Invisalign logo, SmartForce, among others, are trademarks and/or service marks of Align Technology, Inc. or one of its subsidiaries or affiliated companies and may be registered in the U.S. and/or other countries. | MKT-0005669 Rev A – AD

Improvements to predictability in:

Deep bite correction

Posterior arch expansion