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Don’t resist new digital and biological orthodontic technologies

Wayne Hickory, DMD, MS, MDS

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In my orthodontic career, I’ve seen digital technology totally change the way I practice. The new-patient process, diagnostic tools, treatment planning, appliance fabrication and practice management have all been transformed by digital technology. We’ve gone from paper charts, developing films, taking impressions and bending wires to digital files, 3D X-rays, scans, computer-driven aligner fabrication and robotically bent wires.

The new-patient process has been streamlined by digital photography and digital radiographs, allowing the doctor and new-patient coordinator to give patients a vivid view of their orthodontic problems at the first visit. Many patients are so self-conscious about their smile that they’ll look in a mirror at their teeth only momentarily. When their teeth are up on a big screen, it can be very illuminating and motivating for them.

Technologies that give the doctor the power to model treatment with advanced software and then fabricate an appliance with computer-assisted manufacturing have been game-changers in orthodontics. I have been surprised—perplexed, actually—by how slow the profession has been to adopt these amazing technologies. Interestingly, though, they’re based on the fundamentals of orthodontic diagnosis, treatment planning and biomechanics.

Typewriters vs. word processors

I attended the first Invisalign certification course in 1999, and it took me months to submit a first case. As an orthodontic practice we were challenged by PVS impressions, and the Internet was dial-up. The aligner treatment was not as efficient or as effective as braces at that time, but it was still a fantastic alternative for an adult who did not want braces.

As Invisalign has done data mining on more than a million cases and incorporated principles of biomechanics, the product has evolved. In my experience, for many cases, Invisalign now outperforms braces in efficiency and effectiveness. As with any system, understanding the features and experience will be a factor. Having done more than 5,000 Invisalign cases positions us to manage its strengths and weaknesses.

For me, braces are like using a typewriter and Invisalign is like a word processor. With aligners, the 3D movements of all the teeth can occur simultaneously; with braces we need to do stages, with different wire flexibilities employed for different types of movement. Every small amount of movement with aligners is nearly 100 percent useful, because it is highly targeted to a predetermined goal.

Finally, with braces we often need to chase side effects toward the end of treatment and reposition brackets or bend wire. These reasons combined explain why with Invisalign treatment time can be faster, even if tooth movement is slower.

The new age of 3D treatment

I had the privilege of participating in the graduate program at the University of Connecticut, with Drs. Ravindra Nanda and Charles Burstone as my mentors. We did 3D treatment modeling with occlusograms and ceph tracing, with frequent reanalysis with superimpositions to monitor progress. John Morton was in the engineering section of the orthodontic department. Now, as the lead engineer at Align, he has brought Dr. Burstone’s concepts of biomechanics to Invisalign. The core principle remains that to define a tooth’s 3D-position goal, one must design a force system to achieve that goal and then design an appliance to deliver that force system.

Dr. Rohit Sachdeva was a fellow student at Connecticut and brought the same basic principles of 3D treatment planning and biomechanics to SureSmile. SureSmile may be the most sophisticated orthodontic system ever developed. I used SureSmile in its early years and was amazed at its effectiveness.

It’s hard to compete with computer modeling and 3D robotic wire bending. I would use this system more, but I believe that aligners are a better patient experience. Robotically bent wires are especially practical for lingual. I used Lingual Care for many years and I’m interested in SureSmile’s lingual system.

Embracing, not ignoring, new techniques

Most days, I take all the digital technology for granted. Sometimes I do pause and think about how things have changed—for example, on a long flight I can simultaneously do ClinChecks, access patient records and communicate with my office.

Up till now, orthodontic innovations have been focused on how we put forces on teeth. The future of orthodontics will be combining digital orthodontic technology with new techniques that are changing the biological response—techniques such as micro-osteoperforations, vibration and light. The NYU research published in AJO in November 2013, which showed that Propel resulted in more than double the normal rate of tooth movement, is monumental. I don’t think we have ever had anything that was proven to move teeth more than twice as fast, other than a surgical procedure.

There are barriers to incorporating new techniques into a busy practice and there is always resistance to change. So it’s not surprising that adoption of Propel by the profession has been slow, just like with the digital technologies.

I started using Propel more reactively than proactively. That was an easy way to start, because if something was really slow, there wasn’t much to lose. After being impressed with the successes, one has to think of using biological modification more routinely.

New technology always raises the question, “Will this new development allow me to better serve my patients?” For me, the answer has been an emphatic yes. Biomechanics, 3D treatment planning, ClinChecks, Invisalign, Propel—all of it is simply a tool in my hand, like a new pair of pliers. I would not be the clinician I am if I chose not to use the most effective tool in the box. And I believe my patients would not be as well served. So it will be interesting to see what’s coming next. I don’t know about you … but I can’t wait.

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