Will custom orthodontic appliances replace traditional

5/8/2014
Will custom orthodontic appliances replace
traditional orthodontic appliances?
Hero Breuning, DDS,PhD.
Department of Orthodontics and Craniofacial Biology,
Radboud University Nijmegen, The Netherlands
herobreuning@gmail.com
Introduction
Damon (Ormco)
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Individual appliance
Archambault A et al. : Torque expression in stainless steel
orthodontic brackets. Angle Orthod. 2010 (review article).
Wire selection
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Breuning KH. Early full size wires. J Clin Orthod 2011
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Early full size wires
Michael.C.Alpern
Neo Sentalloy (GAC)
Tritanium wire (American Orthodontics)
My first individual appliance:
Hero-System
In-Ovation (GAC) Time + Empower (AO) Victory (3M Unitek)
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Dual activation + bi-dimensional
018
022
• Empower (American Orthodontics)
Breuning KH. Am J Orth Dentfacial Orthop 2008.
Dual activation
Damon Q
Gemini
Prodigy
Victory SL
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Ormco
3M Unitek
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Individually selected torque values
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Breuning KH . Efficient orthodontics-J Clin Orthod 2011.
Straight wire appliance ?
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Andrews LF. The six keys to normal occlusion.1972
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Individual fixed appliance system
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Bracket selection (active/passive)
Slot selection (0.018’ vs 0.022”)
Torque selection
Wire selection
Indirect bonding
Need for custom appliances
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Andrews LF. The six keys to normal occlusion.1972
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Bracket selection
Breuning KH . Efficient orthodontics-J Clin Orthod 2011.
Custom diagnosis and treatment
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Virtual treatment planning in 3D
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Ludlow JB and Walker C. Assessment of phantom dosimetry and image
quality of i-CAT FLX cone-beam computed tomography. AJODO 2013.
Virtual treatment presentation in 3D
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Anatomage (In Vivo)
Dolphin
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Fabrication of custom appliances
• Digital dental models
Heat N Bite (Ormco)
Intra oral scanning
• iTero scanner (Cadent)
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The dentition on CBCT’s
• AnatoModels (InVivo dental)
Accuracy of digital dental models
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I Tero scan
CBCT
Akyalcin S et al. Diagnostic accuracy of impression-free
digital models. Am J Orthod Dentofacial Orthop 2013.
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Accuracy of digital dental models
Plaster
SureSmile
emodels
AnatoModels
• SureSmile models were the most accurate, and reproducible
• emodels were significantly faster than those taken on the other models
Grünheid T et al. Accuracy, reproducibility, and time efficiency of
dental measurements using different technologies AJODO 2014.
Intra oral scanner + software
• -Trios scanner (3Shape) Ortho Analyzer software
• -Ortho Insight software and Facial Insight software
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Digital set up
• Set up Insignia
3Shape
Custom appliances
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Claims of custom appliances
Individual System
Insignia
Custom Damon Brackets
• Shorter treatment
• Improved results
Custom buccal appliances
Insignia (Ormco)
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Pyamide of evicence for Insignia
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Weber DJ 2nd et al. Clinical effectiveness and efficiency of customized
vs. conventional preadjusted bracket systems. J Clinical Orthod 2013.
Literature on efficiency of Insignia
-Final PAR scores, were not significantly different
-The Insignia group had a lower average ABO score
-Treatment time was significantly shorter
-On average 7 fewer appointments needed
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Weber DJ 2nd et al. J Clinical Orthod 2013.
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Selection of appliance
Suresmile
• Shorter treatment
• Improved results
• Invisable
Pyramide of evidence for Suresmile
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Literature on Suresmile
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Saxe AK, Louie LJ, Mah J. Efficiency and effectiveness of SureSmile. World J
Orthod. 2010;11:16-22.
• Alford TJ, Roberts WE, Hartsfield JK Jr, Eckert GJ, Snyder RJ. Clinical
outcomes for patients finished with the SureSmile™ method compared
with conventional fixed orthodontic therapy. Angle Orthod. 2011;81:383-8.
• Sachdeva RC, Aranha SL, Egan ME, Gross HT, Sachdeva NS, Currier GF,
Kadioglu O. Treatment time: SureSmile vs conventional. Orthodontics
(Chic.). 2012;13:72-85.
• Larson BE, Vaubel CJ, Grünheid T. Effectiveness of computer-assisted
orthodontic treatment technology to achieve predicted outcomes. Angle
Orthod. 2013;83:557-62.
Some of the articles are biased
Suresmile
• Treatment time for the Suresmile patients was significantly
shorter 31% (7.2 months) and the result increased with 11%.
to conventional fixed appliance treatment”.
Alford TJ. et al. Angle Orthod 2011.
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Custom wires for invisible appliances
LINGUAL APPLIANCES
• Suresmile
Custom lingual bracket systems
Incognito,Harmony, E braces, etc.
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Pyramide of evidence for Incognito
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Grauer D, Proffit WR. Accuracy in tooth positioning with a fully customized
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lingual orthodontic appliance. Am J Orthod Dentofacial Orthop 2011.
Literature on Incognito
They concluded: “These fully customized lingual
orthodontic appliances were accurate
in achieving the goals planned at the initial setup,
except for the full amount of planned
expansion and the inclination at the second molars. “
Grauer D and Proffit WR. Am J Orthod Dentofacial Orthop 2011.
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Aligners
• Shorter treatment
• Improved results
• Invisable
Pyramide of evidence for Invisalign
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Lagravere MO and Flores-Mir C. The treatment effects of Invisalign
Orthodontic aligners A systematic review. J Am Dent Assoc 2005.
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Conclusions
Lagravère 2005 -Unable to draw strong conclusions
Djeu 2005
-Deficient in its ability to correct large
anteroposterior discrepancies and occlusal contacts
-Finished 4 months sooner
Kravitz 2009
-To learn regarding the biomechanics
Buschang 2013 -Less visits needed (4)
-Shorter treatment duration (5.5 months)
-More expensive
Custom aligners
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• Aligners on printed dental models
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Attachments for aligners
Retention pads
Dimples
Invisalign (Align)
Orthocaps
Ideal Smile (GAC)
Scientific proof of efficiency and efficacy
Custom brackets and wires
Custom Aligners
Custom wires
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Follow up during treatment
• I Tero scanner
Follow up during treatment
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Main advantage of custom appliances
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More predictable treatment
Improved communication with the patient
More delegation possible
Shorter treatment time?
Improved results?
Main disadvantage of custom appliances
Digital planning is time consuming
Custom appliances are more expensive
10 take home messages
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Individual appliances
Indirect bonding
Early full size wires
Reduced radiation for CBCT’s
Intra oral scanners, the orthodontist should have the STL files
Setup in the orthodontic office
The orthodontist corrects the initial set up
Patient selects the appliance
The orthodontist selects the company who will make the appliance
Follow up appliances are needed (Finishing appliances)
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