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

• 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

• Ormco 3M Unitek

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Individually selected torque values

• Breuning KH . Efficient orthodontics-J Clin Orthod 2011.

Straight wire appliance ?

• Andrews LF. The six keys to normal occlusion.1972

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Individual fixed appliance system

• Bracket selection (active/passive)

• Slot selection (0.018’ vs 0.022”)
• Torque selection
• Wire selection
• Indirect bonding

Need for custom appliances

• 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

• 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

• 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

• 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 emodels

SureSmile 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

• 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

• .
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
• 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

• Grauer D, Proffit WR. Accuracy in tooth positioning with a fully customized

• 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

• 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

• 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

• 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

• 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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