Orthodontists and restorative dentists realize the benefits of combining their expertise on complex restorative cases. Digital tools now streamline and enhance the communication on collaborative restorative dental cases, reducing time spent creating, understanding, and communicating treatment plans. Intraoral scanners facilitate sharing of digital records, including STL files that are transformed in treatment planning software into 3D representations of the progression from current to final patient outcomes. 

Research supports the theory that digital tools improve the interdisciplinary orthodontic treatment of adults.¹ These digital tools help clinicians visualize the outcome and determine the degree and direction of the tooth movement necessary.² 

If a picture is worth a thousand words, a 3D physical model is worth exponentially more. The ability of the restorative dentist to scan new patients allows orthodontists to use those scans with sophisticated software to digitally move the teeth to the best possible occlusion within the biological bounds according to the orthodontist’s training and experience. This 3D vision can be sent electronically to the restorative dentist in the form of a video or by courier/personal delivery in the form of a 3D printed model. In addition to presenting the case to the dentist, it serves as a patient education tool and displays the importance of orthodontics to create improved predictability and stability for the restorative portion of the case. This article outlines the process of designing, printing, and presenting these 3D physical models, also known as the 3D treatment letter.

TRADITIONAL COMMUNICATION

Written treatment plans are the traditional method of collaboration on interdisciplinary cases, supplemented by in-person meetings when necessary.

Research suggests that orthodontists and general dentists have differing opinions about how well orthodontists communicate using various forms of media and that collaborating dentists should determine the optimal method of communication on a case-by-case basis.³ It is inherently challenging to communicate 3D orthodontic movement in written format. It can be time-intensive for the orthodontist to wordsmith a letter that thoroughly explains a complex treatment plan as well as for the dentist to absorb and then re-communicate to a patient. It may be especially challenging for dentists new to collaborating with an orthodontist to visualize the predicted tooth movement from written communication.

OPTIMIZED COMMUNICATION

Straighten Up Orthodontics in Clearwater, Fla, created a visualized treatment objective (VTO) workflow in the form of a 3D treatment letter (a 3D printed model showing an anticipated final, pre-restorative result) to address these challenges. Using tooth-movement software, the orthodontist can design and print the equivalent of a digital wax-up of the anticipated final position of the teeth and occlusion after the completion of orthodontic treatment.⁴ The VTO can be shared digitally, hand-delivered, or shipped to the dentist’s office. The referring dentist can receive the 3D model of the orthodontic result in less than a week.

The VTO technique allows the referring dentist to see 3D renderings of the orthodontic solutions to their restorative challenges in a physical model. As a result, dentists can visualize the treatment planning results in days instead of months or years. The dentist can use the model to effectively show the patient the anticipated treatment outcome and communicate the importance of ideal pre-restorative occlusion. A realistic physical representation demonstrates this more efficiently and more thoroughly than words and diagrams. With a VTO in hand, the dentist and patient can picture the rationale for orthodontic treatment. Research suggests that the VTO mockup is realistic⁵ because orthodontists create clear aligners with the same software that rendered the VTO, and they plan treatment according to a deep orthodontic understanding of predictable tooth movements.

The VTO has proven to be a powerful tool in patient education, resulting in increased treatment acceptance. Often, the patient sees the model, understands the importance of occlusion to the restorative case, and can easily imagine the final results. In some cases, the patient might avoid surgical interventions by leveraging the combined expertise of the orthodontist and restorative dentist.

With the electronic transfer of records, including the STL file, the patient also benefits from the elimination of an orthodontic appointment (Table 1).

Straighten Up Orthodontics has employed the 3D treatment letter with 15 local restorative dental practices. These are complex cases for dentists and orthodontists to resolve by collaborating using digital technology, and the physical model relieves a significant burden. In the authors’ orthodontic practice, patients who receive a VTO mock-up demonstrating the advantages of orthodontia as part of their restorative plans accept orthodontic treatment in 90% of the cases. 

Due to the high conversion rate with these patients, the author does not charge the referring dentists nor the patient for the orthodontists’ time spent on case setup, nor for the 3D model. This reduces the dentists’ lab fees they normally pay for a diagnostic wax-up and provides a model they would normally not receive—the final post-orthodontic occlusion in 3D model form. The cost associated with producing the VTO and models consists primarily of the time spent by the orthodontist setting up the case. An orthodontist accustomed to using treatment planning software can plan a complex case as quickly as drafting a letter. In addition, there are some costs associated with printing the model itself. Patients who receive the VTO or model appear less likely to seek second opinions due to the problem-solving approach of a strong restorative team.

WORKFLOW FOR THE VTO

Here is an example of a streamlined process for communicating using a 3D printed VTO:

1. The restorative dentist sends the STL files with a restorative treatment plan to the orthodontist. (In some cases, the patient may come to the orthodontic practice for a formal consultation and digital impression.)

2. The orthodontist creates the orthodontic pre-restorative setup of the case in the uDesign treatment planning software (uLab Systems).

3. The orthodontist or orthodontic staff generates the VTO video and/or 3D printed models, ideally printing the initial and final VTO models for the dentist.

4. The orthodontist sends the 3D treatment letter in a branded box to the dentist.

5. The restorative dentist then uses the 3D-printed models to show the anticipated orthodontic outcome. The general dentist may complete a digital wax-up on a second set of 3D models to show the patient the final anticipated prosthodontic outcome.

With the support of AI and fluency with the digital tools, setup time is streamlined; the orthodontist will typically spend between 5 and 10 minutes creating the VTO digital workup treatment plan. The lab tech then adds articulator attachments to the model and adds the models to the normal 3D print workflow of the office.

The model is printed with articulator attachments to allow the dentist to analyze the case in the proper occlusion. These are typically complex cases, and having an articulator solution for the printed models improves the repeatability of the dentist evaluating the case. Advanced articulated systems enable the models to simulate natural jaw movement, including protrusion, mediotrusion, and laterotrusion.⁶

SUCCESS STORY USING A VTO

Restorative-orthodontic cases are, by their very nature, complex. The following is a typical case that benefited from an interdisciplinary approach. A patient presented to their general dentist with an anterior crossbite at tooth No. 7, supraerupted teeth Nos. 2 and 18, and multiple missing teeth (Figure 1). The patient expressed interest in correcting the anterior crossbite, aligning teeth, and replacing missing teeth. After reviewing the models, the dentist realized the case required an orthodontist to correct the crossbite, intrude supererupted molars, and create proper spacing for restorative work. For the dentist, the questions became “What can the orthodontist do with this case? What limitations does the case present that the ortho cannot overcome and that will alter the restorative treatment plan?” The dental office was able to share a folder with the STL files and patient photos with the orthodontist. Based on this patient information, an orthodontic mockup was created using uLab software and printed for the dentist to use during his treatment plan review with the patient (Figures 2 and 3). A 3D model (Figure 4) showing the case-specific benefits of orthodontic therapy encouraged the patient to pursue the orthodontic consultation and ultimately accept treatment.

Figure 1. Initial photos of the pre-restorative case. The patient presented with an anterior crossbite on No. 7, supraerupted teeth Nos. 2 and 18, and a missing lower incisor.

Figure 2. The case was set up in uDesign treatment planning software (uLab Systems), ready to create a visualized treatment objective (VTO) and export video.

Figure 3. The VTO was created and ready to 3D print and share with the referring dentist.

Figure 4. The printed VTO.

CONCLUSION

The 3D VTO is a revolutionary concept designed to enhance communication between the orthodontist; restorative dentist; and, most importantly, the patient. Rather than using conventional impression material, the digital intraoral scanner provides a much more comfortable patient experience to obtain a full-mouth impression. The digital information can be used to help the orthodontist and restorative dentist discuss and treatment plan ideal tooth positions for the final restorative outcome. When completing the initial treatment consultation, conveying the restorative outcome to the patient can be challenging. In preparation for a large restorative case presentation, a VTO is used to help show the starting dental position of teeth as well as the anticipated tooth position postorthodontic treatment. From this evaluation, a preliminary wax-up can be completed to establish a predictable final prosthetic result. Combining both the anticipated orthodontic and restorative outcomes with the baseline dental condition helps the patient visualize how his or her “dream smile” will be obtained.

When orthodontists work with dentists on complex restorative cases, communication is essential to treatment acceptance. However, letters, phone calls, and in-person meetings do not always succeed in showing the dentist and the patient what is possible with orthodontic treatment. Using treatment planning software to design a case and create a 3D VTO effectively shows restorative dentists and patients what orthodontics can accomplish to enhance their restorative clinical outcomes with more predictability and stability. For Straighten Up Orthodontics, patients move forward with treatment 9 times out of 10, far superior to any referral acceptance rate obtained with traditional communication.

REFERENCES

1. Ogodescu A, Sinescu C, Ogodescu E, et al. Digital tools in the interdisciplinary orthodontic treatment of adult patients. Int J Biol Biomed Eng. 2010;4(4):97-105. 

2. Shantiyai S. Comparison of Digital Treatment Setups and Final Treatment Outcomes of Class II Division 1 Malocclusions Treated with Premolar Extractions. [Master’s thesis]. Las Vegas: University of Nevada, Las Vegas; 2020.  doi:10.34917/19412168

3. Bibona K, Shroff B, Best AM, et al. Communication practices and preferences between orthodontists and general dentists. Angle Orthod. 2015;85(6):1042–50. doi:10.2319/111714-826.1

4. Asakawa S, Al-Musaallam T, Handelman CS. Nonextraction treatment of a Class II deepbite malocclusion with severe mandibular crowding: visualized treatment objectives for selecting treatment options. Am J Orthod Dentofacial Orthop. 2008;133(2):308–16. doi:10.1016/j.ajodo.2006.08.018 

5. Lombardo L, Arreghini A, Ramina F, et al. Predictability of orthodontic movement with orthodontic aligners: a retrospective study. Prog Orthod. 2017;18(1):35. doi:10.1186/s40510-017-0190-0

6. xSNAP. First model with printable articulator. Accessed September 22, 2022. https://www.x-snap.net/index_en.html

ADDITIONAL READING

1. Adel SM, Vaid NR, El-Harouni N, et al. Tip, Torque and Rotations: How accurately do digital superimposition software packages quantify tooth movement? Prog Orthod. 2022;23(1):8. doi:10.1186/s40510-022-00402-x 

2. McLaughlin RP, Bennett JC. The dental VTO: an analysis of orthodontic tooth movement. J Clin Orthod. 1999;33(7):394-403.

3. Melsen B, Fiorelli G. Chapter 5: Treatment Planning: The 3D VTO. In: Melsen B, Luzi C, eds. Adult Orthodontics. 2nd ed. Wiley-Blackwell; 2022: 65- 78. doi:10.1002/9781119775805.ch5 

ABOUT THE AUTHORS

Dr. Layman earned his DMD degree at the Medical University of South Carolina (MUSC). As an orthodontic resident at Vanderbilt University, he was part of a university-wide team charged with creating the EMR system for the Vanderbilt Medical Center. After starting a paperless and digital orthodontic office in 2004, Dr. Layman completed his MBA at the Wharton School, University of Pennsylvania. He is a Diplomate of the American Board of Orthodontics and Fellow of the American College of Dentists. He has conducted seminars for the Vanderbilt Orthodontic Program, MUSC orthodontic program, and the Dawson Academy. He currently teaches at the University of Florida. Dr. Layman opened Straighten Up Orthodontics in 2005 and co-founded the nonprofit Community Dental Clinic in 2011. He can be reached at straightenup@me.com.

Dr. Kiskaddon earned his DMD degree at the University of Florida College of Dentistry. He attended the University of Florida College of Dentistry’s “Advanced Education in General Dentistry” residency in Seminole, Fla, for further training in complex restorative dentistry. Currently, he practices comprehensive general dentistry in Clearwater, Fla. Dr. Kiskaddon also serves as faculty and enjoys teaching dental residents at the University of Florida College of Dentistry. He can be reached at drkiskaddon@cdadental.com 

Disclosure: Dr. Layman is a key opinion leader and speaker for uLab Systems and has a financial interest in the company. Dr. Kiskaddon reports no disclosures. 

The digital evolution in dentistry has had a profound effect on orthodontics and particularly on the use and practice of clear aligners. While clear aligners were viewed for many years as a treatment only for adults with minor correction needs, clear aligners are now the treatment of choice by many clinicians for patients of all ages and treatment needs. The development of intraoral scanning and treatment planning software has led to an increase in the number of clear aligner cases and the increase of clear aligner treatment for comprehensive and complex cases.

Innovation within clear aligner treatment began with clinicians attempting to create their own aligners in-office.^1-3 Initially, treatment was a laborious process where the doctor would have to make a series of plaster casts with reset teeth for each new aligner. While many patients were treated using analog approaches, it was not until the advent of modern clear aligner treatment by Invisalign (Align Technology)  as the first commercial aligner-specific laboratory that clear aligner treatment entered the mainstream dental workflow. Within a short period of time, clear aligners became a treatment modality that clinicians felt comfortable with treating  as they could send  to a commercial laboratory for reliable and expedited treatment. With an ever-increasing demand for aesthetic options in orthodontics, more than 6 million patients have been treated with Invisalign.⁴ As the world of digital dentistry has evolved with intraoral scanning and cone-beam imaging, the clinical workflows for clear aligner treatment have evolved into a completely digital process, and multiple clear aligner laboratories make a variety of aligners that vary based on design and materials. With new software developments, doctors are even able to take the design and manufacturing of clear aligners into the office of the clinician. With the diverse options available to clinicians and consumer education and awareness of clear aligners as treatment options, digital dentistry and aligner production is an ever-expanding area of treatment in both orthodontic and general dental practices.

CASE REPORTS

Case 1: Improving Aligner Treatment Options with Intraoral Scanning

Intraoral scanning has served as a new foundation for starting clear aligner treatment. With the adoption of intraoral scanners for restorative treatment, the application of this technology for clear aligners has greatly expanded clear aligner treatment in the general dental practice. The difficult process of taking full-arch polyvinyl impressions has been replaced with the ease of the intraoral scanning wand. Doctors are able to take intraoral scans and utilize the digital models as a communication tool with patients to discuss malocclusion and the need for both restorative and orthodontic treatment plans.

A patient presented to the author’s office seeking to replace maxillary crowns. To enhance communication between the patient and the laboratory, an intraoral optical scan (CS 3700 [Carestream Dental]) was made (Figure 1). The optical scans were imported into a module within the intraoral scanning software suite (CS ScanFlow [Carestream Dental]) to assist in generating a visual representation of the occlusal problems present (Figure 2). The virtual teeth were manipulated and oriented to improve the aesthetic and occlusal relationship (Figure 3). The patient was thrilled with the clinical presentation, agreed with the clinical treatment plan, and began orthodontic treatment immediately after.

Figure 1. An optical impression made with an intraoral scanner (CS 3700 [Carestream Dental]) for diagnostic purposes to evaluate treatment for the replacement of anterior crowns.	Figure 2. A full-arch intraoral scan was taken to create a digital wax-up and complete assessment of the patient’s treatment needs (CS ScanFlow [Carestream Dental]).
Figure 3. Digital models in articulation gave a visual representation of the patient’s occlusion and demonstrated the need for clear aligner treatment to improve occlusion prior to restorative treatment (CS Model + [Carestream Dental]).	Figure 4. Cone-beam CT (Green CT [Vatech America]) was utilized for the comprehensive diagnosis and treatment planning of orthodontic treatment using micro-osseous perforations.

Case 2: Utilization of CBCT Imaging to Enhance Visualization for a Micro-osseous Perforation

Cone-beam computed tomography (CBCT) technology has created a new standard of imaging for both restorative and orthodontic treatment. CBCT was first utilized in the United States at the Loma Linda University Orthodontics and now has wide acceptance in the dental community for 3D treatment planning of orthodontic, surgical, and restorative treatments. Today, utilization of this technology can lead to complex interdisciplinary treatment plans coordinating a pre-prosthetic clear aligner treatment planning setup for future restorative treatment.

A patient presented with multiple existing implants and fixed restorations and was interested in clear aligner therapy to help align teeth and improve his aesthetics. A CBCT scan (Green CT [Vatech America]) was made with a large field of view to permit rapid visualization of the anatomical structures needed for aligner treatment (Figure 4). The visualization of the images generated afterward allowed for discussion with the patient with his existing implant treatment and how it would impact the limited aligner tooth movement that could be achieved (Figure 5). Furthermore, utilization of the CBCT scan also permitted for visualization of the precise root position to plan micro-osseous perforations (Excellerator RT [Propel Orthodontics]) of the cortical bone to accelerate tooth movement⁵ (Figure 6). In addition to the perforations, high-frequency vibration was utilized to potentially reduce treatment duration.⁵ The patient was thrilled with his result as it reduced his treatment time so that he could complete treatment prior to enrolling in a postgraduate educational program.

Case 3: Invisalign in a Teenage Patient

A teenage patient presented with a concern of diastemas between her teeth. After seeing several other orthodontists, she did not pursue orthodontic treatment as she was given only treatment plans for traditional bracket and wire therapy (Figure 7). After a complete examination, we concluded that while bracket and wire therapy was indicated, she also would be a good candidate for aligner therapy. Optical impressions were made using an intraoral scanner (Mobile True Definition Scanner [Midmark]) and sent to a commercial laboratory (Invisalign [Align Technologies]) for aligner therapy.

Invisalign is considered the original clear aligner laboratory, is long held as the gold standard in clear aligner treatment, and has developed many pioneering innovations in the digital dental field. Invisalign created the first method for digitizing dental models and sectioning into individual teeth to create a digital setup and, together with the software (ClinCheck software [Align Technology]), created a digital ecosystem for designing clear aligner treatment.

The patient presented with significant Class II malocclusion that would necessitate elastic use during aligner therapy. Invisalign has unique features that can treat teenagers with Class II correction with mandibular advancement. Utilizing the ClinCheck software, a treatment plan was developed to incorporate the use of Class II elastics while resolving the spacing in the arches (Figure 8). Furthermore, Invisalign permits using optimized attachments that are computer-designed to aid optimal tooth movement and mechanically enhance the aesthetic scalloped-edge aligner. A comprehensive treatment plan was completed, giving the patient both functional and aesthetic results (Figure 9). The patient was thrilled with not having to get brackets and wires and requested that the aligners be made to begin treatment.

Figure 5. CBCT imaging (Green CT) was utilized to give a 3D representation of the teeth in relation to the supporting periodontal structures and the existing implant and crown restorations.	Figure 6. Micro-osseous perforations were performed with an Excellerator RT hand driver (Propel Orthodontics).
Figure 7. Generalized spacing and Class II malocclusion created compromised smile aesthetics and excess overjet.	Figure 8. ClinCheck software (Align Technology) was utilized to create an ideal treatment setup (Invisalign [Align Technology]).
Figure 9. Completed treatment with spaces closed and Class II malocclusion fully corrected.	Figure 10. Complex malocclusion with an anterior crossbite and detorqued upper incisors.

Case 4: ClearCorrect in a Complex Adult Crossbite Case

An adult patient presented with concerns regarding the aesthetic appearance of her smile. An evaluation reveals that she had an anterior crossbite that can be challenging to treat with aligners (Figure 10). She was not interested in traditional bracket and wire orthodontic treatment and only wished to be treated if she could do aligner therapy.

An expansion of interest in clear aligner therapy has spurred multiple other commercial laboratories to fabricate clear aligners with unique characteristics. ClearCorrect (Straumann) offers a unique aligner design with a straight trimline extending beyond the gingival margin to create a highly retentive aligner and reduce the need for composite engagers on the teeth.^6,7 Intraoral optical scans (TRIOS [3Shape]) were made, and the patient’s scans were sent to ClearCorrect for aligner case setup using software (ClearPilot [Straumann]) unique to its style of aligners (Figure 11). She was thrilled with the clinical presentation and scheduled aligner treatment to begin immediately. The unique design of the aligners aided expansion and movement of the teeth to relieve the crossbite and create a stable occlusion and enhanced the patient’s smile (Figure 12).

Case 5: In-Office Aligner Production

A patient who was currently being treated for conventional aligner treatment in another provider’s office presented with concerns regarding her treatment progress. She felt like she had posterior open-bite and did not feel confident with her concerns being addressed (Figure 13). Optical scans (CS3700) were made to help assist in the visualization of her potential treatment using the modules (CS Model + [Carestream Dental]) built into the scanner software (CS ScanFlow). The new aspect of the digital realm for clear aligner orthodontics is the demand for in-office clear aligners and same-day aligners. Multiple software options are now available that give doctors the ability to take full control of designing clear aligner treatment plans for their offices. The accessibility of in-office 3D printing has made it possible to produce same-day aligners.

The patient’s chief concern for seeking orthodontic treatment was to close the midline diastema and create a more pleasing smile. The use of the automatic set-up function within the software allowed a treatment plan to be developed within minutes (Figure 14). After reviewing the proposed treatment setup, the patient was thrilled and accepted aligner therapy within the author’s office. She felt comfortable knowing that her aligners would be produced by the author with full control of potential movement challenges throughout treatment. The models created within the software were then 3D printed using a desktop-grade 3D printer (SprintRay Pro [SprintRay]), and the aligners (Zendura FLX [Bay Materials]) were fabricated and delivered to the patient the same day (Figure 15).

Figure 11. Treatment setup from ClearCorrect (Straumann).	Figure 12. Completed treatment with correction of crossbite and improvement of incisor position.
Figure 13. Patient pretreatment with midline diastema.	Figure 14. Use of the CS Model + software (Carestream Dental) to create an automated setup for clear aligner treatment.
Figure 15. CS Model + software was utilized to create a sequence of clear aligners for comprehensive patient treatment.

CONCLUSION

Orthodontic treatment with clear aligners has been the ideal vehicle to utilize digital dentistry. The development of intraoral optical scanning, CBCT, and aligner design software has driven the use of clear aligners to an all-time high in dentistry. These rapidly changing areas of technology have facilitated the growth of highly sophisticated clear aligner systems produced by major aligner manufacturers and have created an emerging field of doctor-designed and -fabricated aligners.

References

1. Nahoum HI. The vacuum-formed dental contour appliance. NY State Dent J. 1964;9:385-90.
2. Nahoum HI. The dental contour appliance: a historical review. In: Tuncay OC, ed. The Invisalign system. New Malden, Surrey, United Kingdom: Quintessence; 2006.
3. Kesling HD, inventor. Method of making orthodox appliances and of positioning teeth. U.S. Patent No. 2,467,432. April 19, 1949.
4. Align Technology, Inc. 2020 Annual Report. Tempe, AZ: Align Technology, Inc.; 2021.
5. Alikhani M, Raptis M, Zoldan B, et al. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013;144(5):639–48. doi:10.1016/j.ajodo.2013.06.017
6. Cowley DP, Mah J, O’Toole BJ. The effect of gingival-margin design on the retention of thermoformed aligners. J Clin Orthod. 2012;46(11):697-702.
7. Jones ML, Mah J, O’Toole BJ. Retention of thermoformed aligners with attachments of various shapes and positions. J Clin Orthod. 2009;43(2):113-117.

Dr. Shotell is a board-certified orthodontist and practices in a multi-specialty practice in Sonora, Calif, focusing on the interplay of orthodontics and restorative treatment. She received her DMD degree at Nova Southeastern University and advanced hospital training a General Practice Residency Certificate from The Ohio State University. After spending years in general practice treating a broad range of patients, Dr. Shotell returned to complete a certificate and master’s degree in Orthodontics from Loma Linda University. At Loma Linda University, she focused her training on cutting-edge 3D imaging technology for diagnosis and treatment planning in interdisciplinary dentistry. Dr. Shotell considers education to be her passion and regularly consults and lectures on dental technology, clear aligner therapy, orthodontics, in-office clear aligners, office efficiency and workflow, and teamwork. She shares tips and tricks about orthodontics and clear aligners on social media as Alignerbee.

Disclosure: Dr. Shotell is a clinical consultant for ClearCorrect and Carestream Dental.

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When general practitioners (GPs) add orthodontics to their skill sets, this allows them to produce more beautiful results in the smile zone and, with the right training, will also allow them to treat more complex cases when correcting the occlusion is needed.⁵ Minor tooth movement and limited orthodontics are becoming more and more popular in the general dental practice where treatment is often limited to the maxillary anterior segment. This seems to be a comfortable place to start integrating orthodontics into a general practice. Nevertheless, spending the additional time to learn straight-wire comprehensive orthodontic techniques adds more value to what can be provided and improves the level of service for the patient. The team should be trained so they can be better informed of the services the practice provides. Then, they will be more prepared to discuss the options available and to motivate patients to consider potential treatments. The team can help your patients understand that not only having a beautiful smile is important, but also that many dental diseases can be avoided with orthodontic treatment. The clinician, by serving patients better, can elevate his/her professional status in the community at large and positively affect referrals. This in turn, should provide an increase in practice income—a truly a win-win situation.

ANALYZING YOUR PRACTICE
If you have been toying with the idea of adding something to your practice that would energize it and create excitement, you should first do an analysis. Run a simple report of how many of your patients are in the age range of 10 to 15 years old. Also, find out how many of your female patients are in the range of 20 to 45 years old.

The report showing the number of preadolescents and adolescents provides a snapshot of potential comprehensive (brackets and wires) orthodontic cases. This is an extremely rewarding and fun group of patients. They generally desire the treatment due to social pressure. Their parents generally recognize the need for orthodontics and, therefore, are very accepting of the treatment.³ This is a group that carries with it a large referral potential within the family unit as well as extending outward to their social group. The average fee for comprehensive orthodontics is around $5,000. Let’s say that you have an average-sized practice and that this group contains 150 patients. With proper training, you should be able to easily treat 80% of these cases, and the rest you refer to a specialist in order to take advantage of their additional training. You now have a group of 120 patients. If every one of these patients accepted your treatment, your increase in production that year would be $600,000. At 50% acceptance, your increase would be $300,000, and at 25% it would be $150,000. To be as realistic as possible, landing somewhere in the 50% range is quite feasible. Don’t forget to figure in the increase in new patient revenue. Although there is no way to quantify this in advance, know that it will occur.

Now look at the group of females in the range of 20 to 45 years old. Traditionally, more females accept orthodontic treatment than males, as these women are more likely to be looking for cosmetic improvements.² A reasonable share of treatment will be performed on males, but for analysis purposes, let’s just look at groups that can be quickly marketed to. This particular group is more likely to be interested in minor tooth movement in the smile zone.¹ If you know how to utilize clear aligners, you will then have some very interested patients eager for treatment. A typical fee for one arch is $1,500 to $2,400, keeping in mind that often times it is necessary to treat both arches at the same time. For demonstration purposes, let’s assume that this group represents 500 patients, and that they only need one arch treated. If every patient in this group accepted treatment, you would generate an additional $750,000 to $1.2 million. To be more realistic, a 50% acceptance rate would provide you an additional $375,000 to $600,000, and a 25% acceptance rate would be an $187,500 to $300,000 increase in production.

Knowing what the financial possibilities are, what are the estimated costs? You must first locate a reputable organization (one that preferably participates in the ADA CERP or AGD PACE continuing education sponsorship programs) that offers comprehensive training for GPs. It should have the following characteristics:

1. Provides a sound protocol of diagnosis and treatment that is logical, safe, and repeatable.
2. Offers both classroom and hands-on training.
3. Provides educational reference material in the form of a technique manual and additional technique DVDs.
4. Provides continued mentorship for you as you take on more cases and have questions.
5. Provides training in minor tooth movement in the smile zone as well as comprehensive treatment to correct the molar class.
6. Gives you the skills to know what cases to accept and what to refer.

The tuition cost for a course that has the above criteria can be as low as $4,000. The start-up supplies can be relatively low if one buys supplies as needed, such as one set of brackets, one set of the necessary pliers, minimal number of elastic ties, etc. However, know that there are usually discounts when you buy multiple sets of brackets, ties, pliers, etc. So, for a small investment, you can produce some serious revenue. There is a very short list of like investments in dentistry that will provide such a large return.

The following cases represent only a snapshot of what a GP will be able to do with the proper training.

MINOR TOOTH MOVEMENT
Case 1
Minor tooth movement can be ac­complished using brackets and wires, and a time frame ranging from 3 months to one year. This case example is a 17-year-old female who had a deep bite and possessed a smile that showed excessive gingiva (Figures 1 and 2). The molars were in dental Class I relationship. She came to the office requesting a consultation to discuss the possibility of having porcelain veneers placed. When she was further questioned, she had asked for the veneers not knowing that other options existed.

The dental cosmetic pyramid, as described by these authors, includes bleaching, orthodontics, cosmetic perio­dontics, and then restorative as the top tier.¹ If we did not have the ability to treat this case with orthodontic means, our cosmetic dental pyramid would lack that level. In this situation, the remaining option would be very aggressive. It would have involved extensive surgical crown lengthening and excessive tooth reduction for the porcelain. After educating her as to the options available, she allowed us to place ceramic brackets on both arches and treat her condition with the traditional straight-wire technique combined with interproximal reduction. The case was debracketed 6 months later, and she was placed in upper and lower bonded retainers. The result shows level arches with a normal anterior overbite and overjet, combined with a normal display of gingiva (Figures 3 and 4).

CASE 1 Figure 1. Pre-orthodontic view showing excessive gingival display and deep bite. Figure 2. Retracted view pretreatment. Figure 3. Post-ortho view. Note the balanced gingival margins and level arches. Figure 4. Post-ortho treatment retracted view.

Case 2
A 34-year-old female patient presented with lower arch orthodontic relapse and a Class I molar relationship (Figure 5). There was a substantial amount of crowding present (Figure 6). Although there were malpositioned teeth in the upper arch as well, the patient was only concerned with the lower arch. A straight-wire technique, in combination with interproximal reduction, was used to resolve the crowding and align the teeth.

This case was completed in one year, and a lower bonded retainer was placed to prevent future movement of the teeth (Figures 7 and 8).

CASE 2 Figure 5. Retracted view before treatment. Figure 6. Pretreatment occlusal view showing the malalignment of the lower anterior teeth. Figure 7. Retracted view, post-ortho treatment of the lower arch only. Figure 8. Occlusal view, post-ortho treatment.

Case 3
A 19-year-old female patient presented, seeking orthodontic correction for both arches in the smile zone only. The upper occlusal view shows rotated laterals, while the lower occlusal view shows that all 4 incisors are malaligned (Figures 9 and 10). She was not interested in traditional orthodontics using brackets and wires, but was willing to have her treatment performed using clear aligners.

This case was completed in 5 months using the Essix in-office clear aligner system (DENTSPLY Raintree Essix) combined with interproximal reduction (Figures 11 and 12). Retention was provided using an upper Essix retainer and a lower bonded retainer.

CASE 3 Figure 9. Occlusal pretreatment view of upper arch. Note the rotations of the laterals. Figure 10. Occlusal pretreatment view of lower arch. All 4 incisors are malpositioned. Figure 11. Post-ortho treatment, occlusal view of upper arch. Figure 12. Post-ortho treatment, occlusal view of lower arch.

Case 4
There is an abundance of post-ortho­dontic relapse cases in every practice. Minor tooth movement can rescue these patients and return their teeth to perfect alignment or at least close to it. This 24-year-old patient presented with concerns that his teeth had moved out of alignment even though he had a bonded retainer. Unfortunately, this older-style bonded retainer would not prevent relapse of the incisors because it was not bonded to all 6 teeth from canine to canine. Figure 13 shows that the lower right central incisor was the chief complaint. The old bonded retainer was removed, and an Essix aligner, fabricated in-office, was used to re-align the teeth. The case was taken to completion in approximately 3 months and a new bonded retainer was placed, bonding to all 6 teeth from canine to canine (Figure 14).

CASE 4 Figure 13. Teeth can still rotate unless the retainer is bonded to each tooth. Figure 14. Post-ortho treatment.

Comprehensive Treatment With Traditional Techniques
Comprehensive orthodontic cases will present as frequently as minor tooth movement cases if you can recognize them. These cases are both fun and profitable. Comprehensive orthodontics allows the clinician to correct arch shape, provide lip and cheek support, address trapped or submerged teeth often without extracting teeth, and correct the molar class. Shortcuts and short-term treatments are better suited for adults, but comprehensive treatment is the responsible approach for preadolescents and adolescents.

Case 5
A 12-year-old female patient presented with constricted arches, a Class I skeletal relationship, and Class II molar relationship (Figure 15). Her case took 27 months to complete, and involved upper molar distalization, instead of extracting premolars. In most cases, parents will choose a slightly longer treatment over extracting permanent teeth when given the choice. Post-ortho­dontic retention was provided with an upper Essix retainer and a lower bonded retainer (Figure 16).

CASE 5 Figure 15. Pretreatment retracted view. Note discrepancy in upper and lower midlines and deep bite. Figure 16. Post-ortho treatment.

Case 6
A 10-year-old male patient presented with a Class II skeletal relationship, a Class II dental relationship, constricted arches, and 100% overbite (Figure 17). Due to the severity of his case, it was begun in mixed dentition stage and took approximately 30 months to complete. It involved both upper and lower molar distalization, thereby avoiding premolar extractions. The patient was retained with an upper Essix and a lower bonded retainer (Figure 18).

Adult comprehensive orthodontic cases can also be extremely rewarding for clinician and patient alike. These patients have wanted a beautiful and healthy smile their entire lives, but hesitated in pursuing treatment outside of the general practice environment. These treatment successes become wonderful referral sources for your practice.

CASE 6 Figure 17. Pretreatment view, note deep bite. Figure 18. Post-ortho treatment.

CLOSING COMMENTS
Why should GPs learn to perform orthodontic procedures in their practice? Because, in doing so, they can re-energize their practice, taking it to the next level. It rekindles a higher level of excitement for dentistry for the clinician and the team. With more revenue coming in, goals are achieved and economic freedom becomes a real possibility. If you are a young dentist who still has educational and construction debts to pay off, this is a wonderful way to reduce those debts faster or to even eliminate them. If you are a seasoned dentist, learning orthodontics often provides an intellectual and professional rebirth. Either way, orthodontics is a great fit for the general practice, and it follows that “if the coat feels good, wear it!”

References

1. Nauman A. Patient-friendly short-term orthodontics. Dent Today. 2013;32:106-109.
2. Wędrychowska-Szulc B, Syryńska M. Patient and parent motivation for orthodontic treatment—a questionnaire study. Eur J Orthod. 2010;32:447-452.
3. Dimatteo AM. The straight story on orthodontics in the general practice. Inside Dentistry. 2007;3:46-49.
4. Schlossberg M. Orthodontics. Where does it fit for the GP? AGD Impact. 2003;31:(3)9-13.
5. Morgan J, Presley S. Follow the cosmetic pyramid for optimal aesthetic results. Dent Today. 2012;31:82-87.

Dr. Morgan received her dental degree from the University of Texas Health Science Center at San Antonio. She practices with her husband, Dr. Stan Presley, in Salt Lake City. She has served as a founding member of the South Texas Chapter of the American Academy of Cosmetic Dentistry and has served on the board of directors of the American Orthodontic Society. She lectures internationally on various conservative cosmetic topics, and she teaches an orthodontic continuum for general dentists and pediatric dentists in partnership with Henry Schein Orthodontics Straight Wire Seminars. She can be reached at morganjaimee@hotmail.com, (801) 561-9999, or via the websites orthodontictraining.net and prestigeseminars.com.

Disclosure: Dr. Morgan reports no disclosures.

Dr. Presley received his dental degree from Baylor College of Dentistry in 1977. He is a general dentist practicing with his wife, Dr. Jaimée Morgan, in Salt Lake City. His training at the L. D. Pankey Institute and Dr. Bob Gerety’s straight wire continuum has provided him with a sound cosmetic treatment philosophy. He was one of the founding members of the South Texas Chapter of the American Academy of Cosmetic Dentistry, where he served as secretary and vice president. He lectures internationally and also teaches an orthodontic continuum for general dentists and pedodontists in partnership with Henry Schein Orthodontics Straight Wire Seminars. He can be reached at (801) 561-9999 or via the websites orthodontictraining.net and prestigeseminars.com.

Disclosure: Dr. Presley reports no disclosures.

The following case study utilizes the Propel System (Propel Orthodontics) in conjunction with Invisalign clear aligner therapy (Align Technology). Through a scientifically proven, patented process called micro-osteoperforation, Propel stimulates the alveolar bone to induce an inflammatory response, accelerating tooth movement in the treated areas (significantly increased the rate of tooth movement by 2.3-fold with no significant patient pain or discomfort³) with virtually no patient recovery time.

CASE REPORT
Diagnosis and Treatment Planning
The patient was a 31-year-old female with a chief concern of aesthetics, specifically referencing the “space” between her front teeth. She also noted that her teeth had begun to move considerably following the extraction of her lower molar (No. 19), which occurred 10 weeks prior. The patient also expressed her concerns about finishing treatment as quickly as possible.

Figure 1. Initial composite.

Figure 2. Preoperative x-ray.

The patient presented with an anterior diastema of 2.5 mm between her central incisors. Upper and lower arch length discrepancies, a transpalatal width of 43 mm and mild lower crowding. A maxillary overjet of 4.0 mm, with bicuspid rotations of 10° and an extruded first molar (No. 14) of 2.0 mm (Figure 1) were noted. The patient’s preoperative radiographs (Figure 2) showed a recently extracted molar (tooth No. 19) with a normally healing bony socket site, acceptable restoration integrity, and no decay was noted in the visual examination or in the radiographs.

The treatment goals included rotation of the lower incisors on their axis with minimal proclination in order to avoid possible anterior collision, resolution of the crowding, rounding out the lower arch, and intrusion of the upper molar (No. 14) to allow room for the implant abutment and crown. Correction of the patient’s midline and closing of the patient’s diastema were also primary goals.

Treatment Details
The patient was treated with Invisalign clear aligners in conjunction with the use of Propel to accelerate tooth movement, shorten the total treatment time and enable implant placement during the orthodontic treatment.

Figure 3. Upper progress, 5 weeks.	Figure 4. Lower progress, 5 weeks.
Figure 5. Interproximal reduction.	Figure 6. Propel Excellerator RT (Propel Orthodontics).

A total of 17 upper and 11 lower aligners were used, with the patient changing aligners once every week instead of the standard change interval of every 2 weeks. This change in aligner protocol was possible due to the concurrent use of Propel, essential for expediting the rate of tooth movement and to better aligner tracking with this patient.

At 5 weeks into treatment, the upper spacing and lower crowding were resolved, the arches were sufficiently rounded out, and the implant was placed for tooth No. 19 (Figures 3 and 4). The patient was treated for an additional 5 weeks until tooth No. 14 had intruded and sufficient space was created to allow for the abutment and restoration of tooth No. 19.

Patient Records and Invisalign ClinCheck Treatment Plan
During the first appointment, initial records were taken, including x-rays and iTero digital scans (Align Technology) of both arches with bite. Interproximal reduction (IPR) distal to cuspid tooth No. 11 of 0.5 mm, 0.5 mm distal to the right canine (tooth No. 11) and 0.4 mm distal to the premolars (teeth Nos. 12 and 13) was requested to correct the midline, enable room for intrusion of No. 14, and to achieve better posterior occlusion. IPR of 0.2 mm between the lower incisors (total of 0.8 mm) was requested to resolve crowding (Figure 5). Additionally, as requested, the aligners for the lower arch were modified to be 3 mm short of the gumline to avoid impingement of the gum at the extraction site.

Aligner Delivery and Propel Treatment
Aligner sets Nos. 1 to 5 were delivered at this appointment and attachments were placed on the appropriate teeth as prescribed in the ClinCheck treatment plan.

Prior to any IPR or treatment with Propel, the patient was treated with an effective topical anesthetic gel (10% prilocaine, 10% lidocaine, and 4% tetracaine) (Profound [Steven’s Pharmacy]). The patient was also instructed to use a chlorhexidine rinse (Peridex [3M ESPE]) for 60 seconds, both before and after the Propel treatment. There is no recovery time or swelling associated with this treatment, and numbness experienced by the patient usually wears off about one hour after treatment.

Figure 7a. Propel treatment (Propel Orthodontics).	Figure 7b. Propel treatment.

Figure 7c. Five-mm depth with gutta-percha.

Using the Propel Excellerator RT delivery device (Figure 6), micro-osteoperforations were placed intradentally between the roots from the upper first molar mesial and distal of teeth Nos. 3 to 14 on the upper arch and lower arch from tooth No. 30 to the mesial of tooth No. 20 (Figure 7a). No micro-osteoperforations were performed intradentally for teeth Nos. 18 or 19 (Figure 7b). All prescribed IPR was also performed at this time since the patient was already anesthetized.

As the use of Propel stimulates the alveolar bone to increase cytokine activity and induce an inflammatory response, no micro-osteoperforations were made distally of tooth No. 20 so as not to risk the healing of the post-extraction bone or impending implant.

The depth of the micro-osteoperforations between teeth Nos. 13 and 14 was increased to 5.0 mm in order to create the necessary stimulation to clinically achieve the desired amount of intrusion for tooth No. 14 (Figure 7c; please note the gutta-percha).

Developed by university researchers, Propel is a simple chairside procedure that takes minutes, produces little discomfort to the patient and has been shown to significantly accelerate the rate of tooth movement (2.3 times faster).³

The Propel Excellerator RT was chosen to perform the micro-osteoperforations (as opposed to the original Propel Excellerator device) as it is designed to produce the same results as the original Excellerator device, but with the added benefits of an autoclavable handle and disposable tips to minimize waste and maximize storage efficiency.

Implant Placement
Although normal protocol has the patient returning every 6 weeks for evaluation, at 4 weeks into treatment, the patient returned for a CT scan and evaluation for implant placement.

At this point into treatment, the upper spacing and lower crowding were resolved, the arches were sufficiently rounded out, and the CT scan showed sufficient bone density (Figure 8), for the evaluation of implant to be placed and selected (5.0 x 10 NobelActive Internal RP [Nobel Biocare]).

Figure 8. CT scan.

Treatment After the Propel System
Immediately after performing the micro-osteoperforations with Propel, the patient was given aligner sets Nos. 2 to 6 and was instructed to continue the wear of the first set of aligners for an additional week. This was done to allow time for the micro-osteoperforations to stimulate cytokine activity, accelerating alveolar bone remodeling and enabling accelerated tooth movement. For aligner sets Nos. 2 to 6, the patient was instructed to change aligners every week in order to ensure continuous force from the aligners.

The patient was instructed to return back to office after 6 weeks to evaluate aligner tracking and to check the interproximal contacts. The patient’s compliance and tracking were excellent and no additional use of Propel was needed (typical cases may require one to 2 rounds of Propel throughout the entire course of treatment).

After 12 weeks, all planned movements in both the upper and lower arches were successfully achieved and all attachments were removed. In order to ensure sufficient osseointegration, the placement of the abutment and final restoration on tooth No. 19 was not performed until 3 months after the original implant placement. Taking into account the time for the implant placement and healing, the total treatment time for this case was 14 weeks.

Follow-up photos and radiographs showed that the integrated implant was within normal limits (Figures 9 and 10). The patient was given a Vivera retainer (Align Technology) to be worn approximately 18 hours per day for retention for the first year. A fixed lingual cuspid-to-cuspid retainer was also placed on the lower arch at that time.

One-year post-treatment, it was recommended that the patient return for an implant followup and for an evaluation for an upper splint or continuation of the retention protocol with clear retainers (for nightly wear).

Figure 9. Final retention and restoration.

Figure 10. Final x-rays.

Figure 11. Anterior, one-year postoperative.	Figure 12. Left buccal, one-year post-op.

Figure 13. Right buccal, one-year post-op.

DISCUSSION
With cases that require orthodontic treatment in conjunction with restorative work, patients frequently turn down treatment when the orthodontic treatment has traditionally taken 12 to 24 months and would need to be done prior to the start of the restorative phase of treatment. The use of micro-osteoperforations in this case was essential to minimize the treatment time needed to achieve both the desired orthodontic and restorative treatment goals.

It is well documented that the use of osteoperforations increases cytokine activity and resulting osteoclast and osteogenic activities.⁴ In the short term, this serves to decrease the trabecular bone density, enabling greater movement of teeth in less time. However, as is evidenced in the i-CAT FLX 3D Cone Beam (a brand of KaVo Kerr Group distributed exclusively through Sullivan Schein) imaging scans taken one-year post-implant (Figures 11 to 13), the bone density around the implant area in this patient appears to have been altered, creating more dense patterns of trabecular bone. As is noted in the literature, other minimally invasive orthodontic treatments such as temporary anchorage devices (TADs) result in bone tissue turnover and increased density of the adjacent alveolar bone.⁵ Similarly, localized bone injury as a result of the minimally invasive Piezocision procedure, triggers a cascade of localized events including intensive osteoclastic as well osteogenic activities.⁴ It is hypothesized that in the long term, similar localized bone stimulation as a result of micro-osteoperforations may alter the pattern of the trabecular bone density, resulting in more dense patterns of trabecular bone. Therefore, this technique may be ideally suited for use with combination orthodontic and, in this case, implant placement concurrent with orthodontic treatment.

The beneficial effects on trabecular bone density with this patient have been consistent with the results noted in the more than 50 other clear aligner and micro-osteoperforation cases treated.

CLOSING COMMENTS
The case presented was completed within a shorter treatment time than would be expected with traditional orthodontic treatment alone, without sacrificing ideal clinical goals. As this case also required restorative treatment, the use of micro-osteoperforations was the key to ensuring that the necessary orthodontic goals were achieved, enabling seamless restorative work within a treatment timeframe that was acceptable to both the doctor and patient. The one-year postoperative CT scans (Figures 11 to 13) demonstrate that there is no root resorption and also show more evident density of the bone trabeculae.

References

1. Nicozisis J. Accelerated orthodontics through microosteoperforation. Orthodontic Practice US. 2013;4:56-57.
2. Teixeira CC, Khoo E, Tran J, et al. Cytokine expression and accelerated tooth movement. J Dent Res. 2010;89:1135-1141.
3. Alikhani M, Raptis M, Zoldan B, et al. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013;144:639-648.
4. Keser EI, Dibart S. Piezocision-assisted Invisalign treatment. Compend Contin Educ Dent. 2011;32:46-51.
5. Almuzian M. Orthodontic bone anchorage devices. Glascow, Scotland: University of Glascow; 2013. slideshare.net/almuzian/orthodontic-bone-anchorage-tad-by-almuzian-36418354. Accessed September 3, 2015.

Dr. Ataii received his DMD from the Tufts Dental School and has more than 2 decades of clinical experience. He has treated almost 1,000 patients with clear aligners in combination with oral appliances, most recently utilizing the micro-osteoperforation technique. He has spearheaded numerous beta testing and clinical research projects, resulting in multiple dental journal publications and national television features. He has lectured around the world and is committed to bringing positive changes to dentistry and allowing patients to reap the benefits of modern dental technology. He can be reached at ataiidmd@gmail.com.

Disclosure: Dr. Ataii is a paid speaker for Align Technology, Propel, and 3M ESPE.

INTRODUCTION
As patients seek more conservative dental treatments, well-rounded general practitioners (GPs) will include limited orthodontic services, if not full comprehensive orthodontic care to better serve their patients’ needs and desires. Dental consumers are not as keen on having their teeth irreversibly prepared and porcelain placed in what has been described in recent years as “instant orthodontics.”^1,2 The gross misuse of the term is misleading, and presents an ethical dilemma in that when teeth are prepped for the purpose of aligning and placing porcelain veneer restorations, it is neither conservative nor orthodontic.1 If orthodontic insurance coverage is involved, one would be hard pressed to legitimately file for reimbursement if no orthodontic movement was actually treatment planned, much less achieved. With the orthodontic systems available today, it makes sense to become familiar with one that allows the clinician to integrate a truly conservative treatment option.

The Essix Technique: Background
Many general dentists began their orthodontic journey with a very simple and predictable in-office technique for minor tooth movement and orthodontic retention using Essix appliances. The Essix Technique was developed by Dr. Jack Sheridan and introduced in 1993.³ Dr. Keith Hillard developed specialty thermo-pliers to make the technique more precise and to allow reactivation of the appliance without having to re-impress and make new models.³ The short explanation of the Essix (now DENTSPLY Raintree Essix) system is that an intimately adapted orthodontic aligner is made from the patient’s models and force bumps placed in the aligner using Hilliard Thermopliers (DENTSPLY Raintree Essix) that will safely move a tooth up to 1.0 mm per month. The plastic used to make the aligner is specially formulated to allow temporary deformation of the plastic while the tooth is moving. At the same time, the plastic is rigid enough to put the appropriate force on the tooth, but not so rigid that it fractures or cracks.

Many systems have been introduced since then, but very few if any would prove to be as aesthetic, inexpensive, predictable, and easy to fabricate. Although this technique has myriad attributes, allowing GPs to gradually and confidently add orthodontic care to their practices with little investment for materials and equipment, some have reported that they would prefer an alternate method that would eliminate their direct involvement in the design and fabrication of the aligners, but still remain profitable for the practice and affordable for their patients.

Introduction of a Lab Design and Fabrication System
Recently, DENTSPLY Raintree Essix received FDA approval for their laboratory-designed and fabricated minor tooth movement system, MTM Clear Aligner Service Center (mtmclearaligner.com). This system is unique when compared to other lab fabricated aligner systems in that it evolved from the traditional MTM In-Office system that has been practiced for more than 20 years. The important aspects of using force bumps and reservoirs in the aligner to move target teeth were upgraded into what DENTSPLY Raintree Essix now calls “open pathway architecture,” while facilitating tooth movement using “force points” with no bonded attachments.

MTM Clear Aligner Service Center is a clinician-friendly system because the required training can be accomplished online for a reasonable fee. This training also includes some appealing introductory offers to help the clinician get started. Because the Service Center truly focuses on minor tooth movement, cases submitted will almost always be addressing the teeth in the smile zone. Minor alignment issues, post-orthodontic relapse, finessing orthodontic cases, and prerestorative cases are usually well suited for this system.

This system further simplifies case submission by providing specific criteria to be considered when entering a case. It also allows the clinician to enter his or her own prescription for tooth movement, or to allow the service center to propose the tooth movements for the clinician. If crowding is involved in the area of minor tooth movement, the clinician may enter his or her own prescription for interproximal reduction (IPR) or allow the service center to prescribe the IPR for them. Once the case has been entered, a Case Submission Review will pop up, allowing the user to assess the summary of the case objectives including target teeth (the teeth that are to be addressed), tooth movement, IPR, as well as retention options for when the case is completed (Figure 1). Once the clinician is satisfied with the information entered, the information can be submitted.

Figure 4. Vinyl polysiloxane impressions and bite registration.

Figure 5. Pretreatment photographs of the patient.

Figure 6. Current panoramic radiograph of the patient to be treated.

The MTM Clear Aligner Service Center continues to offer even more support after the case is submitted—one of its experts will personally evaluate the case and develop a proposed treatment plan for review and approval. Once reviewed by the submitting clinician, the treatment plan can be revised if need be according to the clinician’s desires (Figures 2 and 3). Once the clinician approves the case, the aligners go into fabrication. The Service Center will continue to offer clinical and technical support throughout the patient’s treatment.

CASE REPORT
Diagnosis and Treatment Planning
A 25-year-old female patient presented with a chief complaint of malaligned upper lateral incisors. She reported that she previously had comprehensive orthodontics at an earlier age and, after losing her removable retainer, the upper laterals had moved lingually and were now a distraction to her otherwise beautiful smile.

Full upper and lower vinyl polysiloxane (VPS) impressions were taken in addition to a bite registration, pretreatment photographs, and a new panoramic radiograph to send to the MTM Clear Aligner Service Center (Figures 4 to 6). Digital impressions are also acceptable. The clinician may also want to take before and after treatment alginate impressions and have them poured up for record keeping.

Figure 7. Pretreatment photograph of upper arch (occlusal view). Note the obviously malaligned laterals.	Figure 8. Each aligner is delivered from the lab in its own numbered case.

Note the obvious mesiolingual rotations of the upper laterals on this patient’s upper occlusal pretreatment photograph (Figure 7). The photographs and panoramic radiograph were submitted electronically. The VPS impressions and bite registration were put into the provided protective cases with a printout of the proposed treatment plan and sent to the Service Center. One of the advantages of digital impressions is that the entire case can be submitted online, eliminating lag time from shipping. Once the Service Center received the case, a treatment plan was designed based on the recommendations of the dentist, and within a few days, an email was sent to the clinician for approval of the treatment plan.

This case was originally submitted with the target teeth being the upper laterals only. When the Service Center experts reviewed the case, they suggested adding the upper centrals as well to the treatment plan. There is no extra charge for additional aligners, and knowing that someone else is reviewing your case to ensure optimal results is reassuring. Once the clinician approved the case, aligner fabrication began.

In approximately 2 weeks, notification was received that the aligners had been shipped. A detailed treatment plan summary was printed from the patient’s record from the MTM Clear Aligner Service Center website as well as an informed consent form for the patient to read and sign prior to beginning treatment. The informed consent explained the importance of complete compliance for the treatment to be successful. The treatment plan summary indicated where IPR was needed prior to delivery of each aligner, and how much enamel should be removed. This summary also specified the directional forces that each aligner would apply to each target tooth.

This case required 3 aligners for active movement and a fourth aligner for retention. Each aligner was delivered in its own numbered container (Figure 8). Included with the aligner container were instructions for the patient, including the cleaning and care of the aligners along with aligner removal tools and Retainer Brite cleaning tablets. For the clinician, by reviewing the detailed treatment plan summary provided by the MTM Clear Aligner Service Center, it is easy to understand what tooth movement each aligner will provide (Figures 9 to 14).

IPR was required in only one area (in the amount 0.25 mm) on the mesial of the upper left canine (tooth No. 11) prior to the delivery of the first aligner. The IPR was easily and safely carried out with a safe-sided medium-grit Flexview (DENTSPLY Raintree Essix) strip using an appropriate measuring gauge (DENTSPLY Raintree Essix) (Figure 15). The tooth was then finely polished and treated with neutral sodium fluoride. The first aligner was then tried in. Instructions for wear and care of the aligner were reviewed with the patient, and she appointed to return to the office in 4 weeks.

Figures 9 to 14. These images show a detailed summary of what each aligner would be addressing.

At the next visit, tooth movement was assessed. Reviewing the detailed treatment plan summary provided by the Service Center, it was easy to determine if the correct tooth movement had occurred. In her case, the appropriate teeth had moved into their proper positions for that aligner, and the next aligner was delivered. Appointments should be, and were, 4 weeks apart until completion of the case.

Figure 15. Minimal interproximal reduction was easily and safely done with a safe-sided medium-grit Flexview strip (DENTSPLY Raintree Essix) using the appropriate measuring gauge (DENTSPLY Raintree Essix).	Figure 16. Post-treatment occlusal view.

Once the target teeth were in their proper positions as dictated by the treatment plan summary, retention was the final step of the case (Figure 16). A removable Essix retainer, a Hawley retainer, or a bonded retainer may be used. Regardless of the method, post-orthodontic retention is a must to prevent relapse.⁴ In this case, the patient preferred to have a removable Essix retainer instead of a bonded retainer.

CLOSING COMMENTS
This system is a much-needed service for GPs and specialists alike. It is clinician friendly, and generous support is provided by the experts at the Service Center for any clinician who is not experienced with orthodontic treatment. Also, there is no limit to the number of aligners needed to complete the case, once the case is accepted by the MTM Clear Aligner Service Center and approved by the doctor. The required training can be accomplished online, so no expensive travel or time out of the office is necessary. The fee for this service is reasonable, which means affordability for the patient while still maintaining a healthy profit margin for the practice. The convenience factor for both the clinician and patient, of not having to refer the orthodontic services out for this kind of treatment, is immense.

References

1. Jacobson N, Frank CA. The myth of instant orthodontics: an ethical quandary. J Am Dent Assoc. 2008;139:424-434.
2. Elashvili A, Denehy GE. Instant orthodontics: a case report using direct resin composite for malpositioned anterior teeth. Inside Dentistry. 2010;6:54-56.
3. Sheridan JJ, Hillard K, Armbruster P. The Essix appliance technology: applications, fabrication and rationale. Am J Orthod Dentofacial Orthop. 2003;124:749.
4. Parker WS. Retention—retainers may be forever. Am J Orthod Dentofacial Orthop. 1989;95:505-513.

Dr. Morgan received her dental degree from the University of Texas Health Science Center at San Antonio. She practices with her husband, Dr. Stan Presley, in Salt Lake City. She has served as a founding member of the South Texas Chapter of the American Academy of Cosmetic Dentistry and is on the board of directors of the American Orthodontic Society. She lectures internationally on various conservative cosmetic topics, and she teaches an orthodontic continuum for general dentists and pedodontists in partnership with Henry Schein Orthodontics Straight Wire Seminars. She can be reached at (801) 561-9999, at morganjaimee@hotmail.com, or via the websites orthodontictraining.net and prestigeseminars.com.

Disclosure: Dr. Morgan discloses that funding for this article was provided by DENTSPLY Raintree Essix.

Dr. Presley received his dental degree from Baylor College of Dentistry in 1977. He is a general dentist practicing with his wife, Dr. Jaimée Morgan, in Salt Lake City. His training at the L. D. Pankey Institute and Dr. Bob Gerety’s straight wire continuum has provided him with a sound cosmetic treatment philosophy. He was one of the founding members of the South Texas Chapter of the American Academy of Cosmetic Dentistry, where he served as secretary and vice president. He lectures internationally and also teaches an orthodontic continuum for general dentists and pedodontists in partnership with Henry Schein Orthodontics Straight Wire Seminars. He can be reached at (801) 561-9999 or via the websites orthodontictraining.net and prestigeseminars.com.

Disclosure: Dr. Presley discloses that funding for this article was provided by DENTSPLY Raintree Essix.

Dentistry has benefitted from a number of new advances during the past decade. One of the largest and most dynamic areas of growth is orthodontics. The introduction of Invisalign (in 1999) became a game changer for GPs. Prior to this, a GP would follow one of 3 paths related to orthodontics:

• The GP would express a devoted interest and pursue an orthodontic residency.
• The GP would express interest, preferring to remain in general practice and taking continuing education courses to gain orthodontic competence.
• The GP would simply refer all orthodontics to a local orthodontic specialist.

Figure 1. Cytokine cascade.

Figure 2. AcceleDent Aura with mouthpiece (courtesy of acceladent.com).	Figure 3. SoftPulse Technology Illustration (courtesy of acceladent.com).

I feel these options were largely the result of predoctoral orthodontic training in the United States. The sheer volume of material taught during dental school limited the time available to learn traditional orthodontic techniques. Another challenge was the ability of a predoctoral candidate to have the time necessary to treat a case from start to finish. Both the time to properly diagnose and treat a case, combined with the multiple administrative layers of clinical practice, made continual patient care very difficult, if not impossible.

Traditional orthodontic diagnosis, and an emphasis on mastering specific techniques, required a tremendous time commitment. Thankfully, dental schools have started shifting to competency-based education in predoctoral clinical orthodontics.¹ The net result has been the ability for students and practicing GPs to perform some of the more simple cases involving minor tooth movement that were previously referred to orthodontic specialists.

The ease with which clear aligner therapy has been utilized to accomplish both diagnosis and treatment of minor tooth movement has been incredible. ClinCheck Software (Aligntech Institute) allows a doctor to accurately predict tooth movement as well as any challenging or stubborn areas.² The ability to use the Align ClinCheck Software to visualize the final results is based on protocols developed with a database of more than a million cases, combined with rigorous lab testing using multiple force measurement apparatuses. The combination of these in vivo and in vitro analyses has resulted in increased confidence for practitioners.³

Just as with any procedure or technique in dentistry, proper training, case selection, and attention to diagnosis are keys to success. Also, starting with simple cases will act as a catalyst for excellent outcomes and patient satisfaction. The mantra crawl, walk, run applies to minor tooth movement, as it does for endodontics, oral surgery, or restorative procedures.

The past few years have seen an increased emphasis on reducing treatment times in orthodontics. The speed and velocity of tooth movement has been associated with potential iatrogenic external apical root resorption (EARR) of tooth roots.^4-6 This phenomenon has not been observed with clear aligner treatment in more than a decade and a half, since Invisalign was introduced.^7-9 I feel that the greatest reason for the lack of EARR with clear aligner therapy is simply due to the fact that, if the device is changed to a new one too quickly, the plastic deforms and the tooth will not “track” properly. This potential “excess velocity safety mechanism” has led to the consideration of alternative methods to orthodontically move teeth quicker.

Interestingly, the concept of accelerated tooth movement has developed on a parallel path with clear aligner therapy. Although the idea of speeding up tooth movement is not new, many new methods have been developed to accomplish this with reduced deleterious effects.^10,11 A nice analogy might be to consider teeth the equivalent of fence posts in the ground. It would be very difficult to drag a fence post through solid concrete. But it would be easier to move it through soft earth, and even easier to move the post through wet concrete. How does one turn cured concrete into a softer substrate?

Let’s consider the standard forces associated with moving a tooth through jawbone. When a tooth has force placed on it, mechanically induced bone remodeling occurs. Bone is resorbed (via osteoclasts) on the compressive side and laid down (via osteoblasts) on the tension side of the tooth. Norton and Burstone12 and Kusy and Tulloch¹³ describe 3 distinct phases of force:

• Initial or strain phase. Occurs during a very short time period when the initial force is applied.
• Lag phase. Hyalinization tissue forms during this 2- to 3-week period, with little or no tooth movement.
• Post-lag phase. Tooth movement rapidly occurs as the hyalinized layer is removed, and the bone undergoes resorption via osteoclast action.

Oppenheim¹⁴ and Schwarz¹⁵ performed studies determining that the optimal tooth movement force is equivalent to capillary pulse pressure—approximately 20 to 26 g/cm² of root surface.

Armed with this information, a number of new approaches have been developed to move our “fence posts” through a softer substrate while honoring Burstone’s time-proven force model. All these methods rely on a similar common theme known as a regional acceleratory phenomenon (RAP).¹⁶ Again, the idea is simple: use light mechanic forces on the tooth to move it through “softer bone” (Figure 1).^17,18

Let’s now review of the different modalities associated with accelerated orthodontics.

CYCLIC FORCES (VIBRATION)
The principle behind the use of a vibratory method is to place light, alternating forces on the teeth via mechanical or electromagnetic pulses called AcceleDent SoftPulse Technology (AcceleDent). This results in a reportedly reduced second (lag) phase of force promoting greater movement and reduced potential resorption (EARR).^19,20

The AcceleDent system, FDA approved and first introduced in 2009, focuses on the application of low magnitude cyclic forces by having the patient bite on a rubber interdental bite surface for 20 minutes each day. The device is relatively easy to use, but it has a steep cost component ($1,200, at press time) and relies heavily on dedicated patient compliance (a potential challenge). The device is lightweight, rechargeable, and has the ability to download patient use data to a computer (Figures 2 and 3).²¹

PHARMACEUTICAL ENHANCED TOOTH MOVEMENT
Many different forms of pharmacotherapy are being evaluated to enhance tooth movement, including injections of vitamin C and D metabolytes,²² calcitrol,²³ corticosteroids, and many other compounds.^24-26 This ongoing area of research deserves attention as these advances may become a routine part of treatment.

LIGHTWAVE ACCELERATED TOOTH MOVEMENT
OrthoPulse Light Accelerated Orthodontics
Biolux Research, located in Vancouver, Canada, originally developed a product to accelerate bone regeneration after extractions and healing for implant placement. Recently, the company has been completing clinical trials for a product developed for orthodontics called OrthoPulse. Both products rely on the use of near-infrared light emitting diode (LED) therapy or photobiomodulation to accomplish accelerated bone remodeling. The photobiomodulation mechanism involves using Cytochrome c oxidase present in the cell mitochondria to absorb OsseoPulse photons and convert the electromagnetic force energy into chemical energy (ATP).^27,28

The OsseoPulse system involves wearing a device that fits over the patient’s head, similar to a telephone headset. Light is delivered from an LED source extraorally to the site requiring treatment for extractions and implants.

The Biolux Company saw benefit for this technology in accelerating orthodontic movement and developed an intraoral version of the device. The design is reminiscent of a football mouthguard, working with both traditional and clear aligner orthodontic therapy (Figure 4).

Photobiomodulation has seen significant clinical research throughout the years,^29-32 including pharma-induced combination treatment.³³ Loos et al³⁴ are conducting clinical trials to evaluate efficiency and effectiveness of this exciting technology.

Laser-Assisted Accelerated Tooth Movement
Another recent area of interest is the use of laser energy in enhancing tooth movement. Although this area has seen significant lab research during the past decade, no viable commercial clinical system is presently available to the dental community (to the best knowledge of this author).^35-38 I expect significant advances in the area of low-energy laser irradiation in the coming years (Figure 5).

DECORTICATION TECHNIQUES
Probably the most well-known methods of accelerating tooth movement are decortication techniques. This involves creating an iatrogenic insult in the bone/periodontal area near the teeth to be moved. The bone is subjected to mild trauma, resulting in a weakened condition that produces a transient osteopenia (bone healing). In essence, the bone area near the trauma “softens” (just like our fence post analogy), allowing the teeth to move through a less resistant substrate.^39,40

Figures 4a to 4c. OrthoPulse device (courtesy of bioluxresearch.com). (Note from manufacturer: While not currently for sale in the United States and not yet having FDA approval, US and international clinical trials are underway for the OrthoPulse device.)

Figure 5. AOO via laser therapy.

Wilckodontics
Pioneered by orthodontist Thomas and periodontist William Wilcko, accelerated osteogenic orthodontics (AOO) was first introduced in 1998. AOO, often referred to as Wilckodontics^41-45 usually involves performing a periodontal flap procedure followed by incisions or perforations in the bone between the teeth (Figure 6).

AOO is a fairly invasive procedure and has been primarily performed when a periodontal component of treatment is indicated. Osteotomies performed via the Wilcko technique generally involve incisions in the cortical bone along the long axis between the teeth and below the tooth apex. A handpiece and bur are used with copious amounts of irrigation. Manual instruments may be employed but lack the precise control of motor driven instrumentation. Microsaws are also used with the Wilcko technique. Treatment times have been reported to be twice as quick as normal orthodontic treatment.

Figures 6a to 6c. Corticotomies via Wilckodontic Technique (courtesy of wilckodontics.com).

Figures 7a to 8. Pezio micro incision technique through tissue. The markers in the left photo identify where the piezocisions are to be made (courtesy of scielo.cl).

Piezocision
Piezocision is a fairly new technique for performing osteotomies with accelerated orthodontics.46-50 The incisions follow a similar pattern to the Wilcko technique, but a piezosurgical device is used instead of a handpiece and bur. The piezo device uses ultrasonics with a modulated frequency and precise control of the vibrations at the device tip. The piezosurgical device operates along the same principles of the Stryker saw of a Cavitron (DENTSPLY Professional) unit. Advantages of a piezo device over rotary instrumentation include less heat, vibration, collateral tissue damage, pressure, and bleeding. Operators also report better control and precision when using piezosurgical versus rotary instrumentation (Figure 7).
Researchers are now evaluating the surgical results of piezocision through the soft tissue, or via microincisions without performing a periodontal flap procedure (Figure 8).⁵¹

Microperforation Technique in Accelerated Orthodontics
The most popular and promising advance in accelerated orthodontics for the GP involves microperforation with the Propel (Propel Orthodontics) device.

The Propel device utilizes similar physiologic science as the other 2 surgical methods listed above without the extreme invasiveness found with flap surgery or even microincisions. Like the others, Propel utilizes the RAP phenomenon to create a localized area of trauma, which in turn begins bone remodeling via a process known as cytokine expression.⁵² Simply put, these cytokine chemical messengers allow the surface of the osteoblasts to undergo receptor activation of nuclear factor-kappa ligand gene expression (also known as RANKL). Once again, our fence posts can now move through softer quicksand instead of hard concrete.⁵³

Figure 9. Original Propel Excellerator device.

Figures 10a to 10e. Propel (Propel Orthodontics) device in action.

The technique for the Propel device requires no surgical instrumentation and can be performed in a standard dental operatory employing traditional aseptic protocol. The practitioner simply places very small microperforations in the cortical bone, directly through the gingival tissue. This microperforation of the cortical plate through the gingival soft tissue has been referred to as alveocentesis.⁵⁴ Generally 2 or 3 perforations are placed between each tooth and may be limited to teeth that require challenging movements or an entire arch.55

An area of localized inflammation occurs in the peripheral tissues surrounding each perforation, resulting in bone remodeling. Because the perforations are one to 2 mm in diameter, this minimally invasive technique causes only mild patient discomfort. The cost is about $120 per disposable device (Figure 9).

The Propel device is a single-use, sterile, disposable manual perforator similar in size to a small handheld screwdriver. The device tip is pointed surgical stainless steel, 1.6 mm in diameter at its widest aspect, with a usable length up to 7.0 mm. The device has a protective sleeve that allows the practitioner to preset depths at one, 3.0, 5.0, or 7.0 mm.

Propel’s 1st generation device (Figure 9) had a plastic handle that was designed to be held in the palm of the hand, with the thumb and one or 2 fingers holding and twisting the shaft to the preset depth (Figure 10).

A 2nd generation Propel device was recently introduced that has a heavier, balanced metal handle and disposable screw tips. I have found the 2nd generation Propel device to be much more user friendly with less plastic waste. The metal handle, slightly wider than a dental handpiece, fits comfortably in the user’s palm and provides better heft for placing the perforations. Another significant improvement is the redesigned sleeve over the tip, which now rotates freely, preventing binding of the gingival tissue (Figure 11).

CASE EXAMPLES
Case 1
Invisalign and Propel—Two Propel applications were performed at the beginning and 10 weeks into treatment. Twenty-four aligners were used at 11-day intervals, no refinement, and total treatment time was 9 months. Two acetaminophen tablets were taken for discomfort at the time of Propel treatment and none the next day. Patient was comfortable a day later (Figures 12 and 13).

Case 2
Invisalign and Propel—Three Propel applications were performed, one at the beginning then at 12-week intervals for the next 2 applications. Thirty-three aligners were used at a 9-day interval. Four refinement aligners were used. Total treatment time was 11.5 months. Two acetaminophen tablets were taken for discomfort at the time of Propel treatment and none the next day (Figures 14 and 15).

The patients presented in both cases were thrilled with their new smile and to have completed treatment in significantly less time than originally indicated. (Cases and photos courtesy Dr. Ben Miraglia.)

Figure 11. Propel Excellerator RT.

Figures 12a to 12e. Case 1, pre-op.

Figures 13a to 13e. Case 1, post-op. (Case and photos courtesy Dr. Ben Miraglia.)

Figures 14a to 14e. Case 2, pre-op.

Figures 15a to 15e. Case 2, post-op. (Case and photos courtesy Dr. Ben Miraglia.)

CLOSING COMMENTS
Like other acceleratory orthodontic techniques, micro-osteoperforation is relatively new to dentistry. As with any dynamic product or technique in the early adoption phase of growth, questions abound concerning safety and efficacy. I will address some of these concerns below.

How does a GP introduce the Propel technique to a potential patient?

As with any dental procedure, proper training and informed consent are necessary before starting, including all risks and benefits. A discussion should include discomfort associated with the mildly invasive “dimpling” procedure and possible side effects. The tradeoff for decreased treatment time and/or better clinical results should be reviewed with the patient.

What if a micro-osteoperforation is too close or violates the periodontal ligament space?

Presently there is very little literature available concerning damage to the PDL during micro-osteoperforation. Discussion with clinical early adopters reveals that these insults heal without complication.⁴⁸ More definitive research is necessary to support this anecdotal information.

How do you manage patient discomfort post-treatment?

Only acetaminophen or paracetomol (Tylenol) analgesics are indicated for patient discomfort. If a more potent medication is indicated, an acetomenaphin/oxycodone combination is recommended (Percocet). Standard nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated for using as pain control because the mechanism of action is to reduce inflammation, a key component in any of the decortication techniques. Acetaminophen (or paracetamol) works by blocking chemicals that send pain messages and helps to cool the body. Ibuprofen, such as Advil and Motrin, is an NSAID that stops the body’s production of pain-causing chemicals and reduces fever and swelling. Acetaminophen is not an NSAID and, as such, will not inhibit the acceleratory orthodontic process.

What is the likelihood of post-op infection?

Because the Propel procedure is minimally invasive (compared to the other techniques described), no antibiotics are indicated.

Are there any contraindications to performing micro-osteoperforation procedures?

As with any dental procedure, a full medical history is indicated (with a follow-up consultation with the patient’s physician for any noted concerns). Other contraindications may include (not a complete list):

• Patients with bleeding or immune disorders
• Patients with high anxiety
• Patients requiring prophylactic antibiotics
• Patients taking or with a history of bisphosphonate use
• Patients taking anti-inflammatories
• Patients who have had previous radiotherapy of the jaw.

In Conclusion
Numerous new methods of acceleratory orthodontic treatment have been introduced recently (Table). More research is necessary to substantiate claims and enhance technology and techniques. The new Propel device used in conjunction with clear aligner therapy offers an efficient and predictable method of acceleratory orthodontic treatment for the GP.

References

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23. Al-Hasani NR, Al-Bustani AI, Ghareeb MM, et al. Clinical efficacy of locally injected calcitriol in orthodontic tooth movement. Int J Pharm Pharm Sci. 2011;3(suppl 5):139-143.
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25. Chumbley AB, Tuncay OC. The effect of indomethacin (an aspirin-like drug) on the rate of orthodontic tooth movement. Am J Orthod. 1986;89:312-314.
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27. Eells JT, Wong-Riley MT, VerHoeve J, et al. Mitochondrial signal transduction in accelerated wound and retinal healing by near-infrared light therapy. Mitochondrion. 2004;4:559-567.
28. Ying R, Liang HL, Whelan HT, et al. Pretreatment with near-infrared light via light-emitting diode provides added benefit against rotenone- and MPP+-induced neurotoxicity. Brain Res. 2008;1243:167-173.
29. Coombe AR, Ho CT, Darendeliler MA, et al. The effects of low level laser irradiation on osteoblastic cells. Clin Orthod Res. 2004;4:3-14.
30. Campanha BP, Gallina C, Geremia T, et al. Low-level laser therapy for implants without initial stability. Photomed Laser Surg. 2010;28:365-369.
31. Khadra M, Lyngstadaas SP, Haanaes HR, et al. Effects of laser therapy on attachment, proliferation and differentiation of human osteoblast-like cells cultured on titanium implant material. Biomaterials. 2005;26:3,503-3,509.
32. Karu TI, Pyatibrat LV, Kolyakov SF, et al. Absorption measurements of cell monolayers relevant to mechanisms of laser phototherapy: reduction or oxidation of cytochrome c oxidase under laser radiation at 632.8 nm. Photomed Laser Surg. 2008;26:593-599.
33. Kim, SJ, Moon SU, Kang SG, et al. Effects of low-level laser therapy after Corticision on tooth movement and paradental remodeling. Lasers Surg Med. 2009;41:524-533.
34. Loos, S, Shaughnessy, T, et al. Ongoing clinical research and evaluation. Canton and Suwanee, GA.
35. Yoshida T, Yamaguchi M, Utsunomiya T, et al. Low-energy laser irradiation accelerates the velocity of tooth movement via stimulation of the alveolar bone remodeling. Orthod Craniofac Res. 2009;12:289-298.
36. Yamaguchi M, Hayashi M, Fujita S, et al. Low-energy laser irradiation facilitates the velocity of tooth movement and the expressions of matrix metalloproteinase-9, cathepsin K, and alpha(v) beta(3) integrin in rats. Eur J Orthod. 2010;32:131-139.
37. Altan BA, Sokucu O, Ozkut MM, et al. Metrical and histological investigation of the effects of low-level laser therapy on orthodontic tooth movement. Lasers Med Sci. 2012;27:131-140.
38. Kawasaki K, Shimizu N. Effects of low-energy laser irradiation on bone remodeling during experimental tooth movement in rats. Lasers Surg Med. 2000;26:282-291.
39. Baloul SS, Gerstenfeld LC, Morgan EF, et al. Mechanism of action and morphologic changes in the alveolar bone in response to selective alveolar decortication-facilitated tooth movement. Am J Orthod Dentofacial Orthop. 2011;139(suppl 4):S83-S101.
40. Yu JY, Lee W, Park JH, et al. Histologic effects of intentional-socket-assisted orthodontic movement in rabbits. Korean J Orthod. 2012;42:207-217.
41. Wilcko WM, Ferguson DJ, Bouquot JE, et al. Rapid orthodontic decrowding with alveolar augmentation: case report. World J Orthod. 2003;4:197-205.
42. Wilcko MT, Wilcko WM, Pulver JJ, et al. Accelerated osteogenic orthodontics technique: a 1-stage surgically facilitated rapid orthodontic technique with alveolar augmentation. J Oral Maxillofac Surg. 2009;67:2149-2159.
43. Wilcko WM, Wilcko T, Bouquot JE, et al. Rapid orthodontics with alveolar reshaping: two case reports of decrowding. Int J Periodontics Restorative Dent. 2001;21:9-19.
44. Sharath K, Amitha R, Biju T, et al. Periodontally accelerated osteogenic orthodontics: review on a surgical technique and a case report. Journal of Interdisciplinary Dentistry. 2012;2:179-184.
45. Einy S, Horwitz J, Aizenbud D. Wilckodontics—an alternative adult orthodontic treatment method: rationale and application. Alpha Omegan. 2011;104(3-4):102-111.
46. Jofre J, Montenegro J, Arroyo R. Rapid orthodontics with flapless piezoelectric corticotomies: first clinical experiences. Int J Odontostomat. 2013;7:79-85.
47. Keser EI, Dibart S. Sequential piezocision: a novel approach to accelerated orthodontic treatment. Am J Orthod Dentofacial Orthop. 2013;144:879-889.
48. Uzuner FD, Darendeliler N. Dentoalveolar surgery techniques combined with orthodontic treatment: a literature review. Eur J Dent. 2013;7:257-265.
49. Yu H, Jiao F, Wang B, et al. Piezoelectric decortication applied in periodontally accelerated osteogenic orthodontics. J Craniofac Surg. 2013;24:1750-1752.
50. Grenga V, Bovi M. Corticotomy-enhanced intrusion of an overerupted molar using skeletal anchorage and ultrasonic surgery. J Clin Orthod. 2013;47:50-55.
51. Mittal SK, Sharma R, Singla A. Piezocision assisted orthodontics: a new approach to accelerated orthodontic tooth movement. Journal of Innovative Dentistry. 2011;1. journal.pdmdentalcollege.com/issue1/reviewarticle/article5.html. Accessed on September 10, 2014.
52. Teixeira CC, Khoo E, Tran J, et al. Cytokine expression and accelerated tooth movement. J Dent Res. 2010;89:1135-1141.
53. Hoogeveen EJ, Jansma J, Ren Y. Surgically facilitated orthodontic treatment: a systematic review. Am J Orthod Dentofacial Orthop. 2014;145(suppl 4):S51-S64.
54. Khoo E, Tran J, Raptis M, et al. Accelerated Orthodontic Treatment [research paper]. Presented at New York University Orthodontic Conference; New York, NY, November 2011.
55. Alikhani M, Raptis M, Zoldan B, et al. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013;144:639-648.

Dr. Gray is a 1986 graduate of Georgetown University School of Dentistry. He is also a graduate of the Pacific Aesthetic Continuum and the Pankey Continuum. He is a Master and Lifelong Learning and Service Recognition in the AGD and a Fellow in the International Congress of Oral Implantologists, International College of Dentists, and Academy of Dentistry International. The ADA appointed him as one of 2 practicing general practitioners (GPs) to the Council on Scientific Affairs. He is also an instructor at the L. D. Pankey and Dawson Institutes and 9 universities. He is the longest-tenured faculty member at Align Technology and has certified more than 19,300 GPs in the Invisalign process since 2001. He is an Invisalign Premier Provider and maintains a full-time, fee-for-service, private practice in Washington, DC. A number of dental manufacturers and nonprofit clinical research facilities rely on his input for product evaluation, research and development. He has been listed as one of Dentistry Today’s Leaders in Continuing Education since 2006 and has lectured on new dental technologies in more than 200 US cities and 10 countries since 1994. He can be reached at (202) 244-4111 or via e-mail at info@smiledc.com.

Disclosure: Dr. Gray is a faculty member at Aligntech Institute (Align Technologies).

INTRODUCTION
Patient expectations are increasingly including enhancements to their overall facial macroaesthetics as well as their dental microaesthetics.¹ Treatment options to address these issues include the use of a paralyzing material such as Botulinum toxin type A (Botox). Indeed, cosmetic injection around the lips and perioral area is thought to be a way to provide aesthetic improvement of age changes around the mouth as well as lip augmentation.² It has also been suggested that intramuscular injection of Botox is an effective way of preventing damage to dental hard tissues and restorations by deprogramming the muscles responsible for the destructive forces.³ But, despite the invasive nature of these procedures, injection of dermal fillers has also been deployed for facial soft-tissue augmentation.⁴ Unfortunately, there have been some adverse reports on injectable, nonbiodegradable fillers.⁵ Therefore, noninvasive, natural methods of craniofacial enhancement might be preferred.
This case study reports clinical changes that are consistent with increased craniofacial symmetry and volume.

CASE REPORT
Diagnosis and Treatment Planning
A 45-year-old female with no relevant medical history requested treatment for the improvement of her smile. On examination, it was found that the upper arch was narrow with a high palatal vault. Facial and intraoral photographs were taken as well as a 3-dimensional (3-D) cone beam computed tomography (CBCT) scan (which revealed no adverse findings).

Clinical Protocol
Vinyl polysiloxane impressions (Correct Quick [PENTRON]) were taken for study models, and a DNA appliance was fabricated. This device consisted of 6 (patented) 3-D axial springs for the anterior teeth, Adams clasps on the first molars, a midline jackscrew, a labial bow extending from cuspid to cuspid, and bilateral occlusal coverage (Figure 1).
Prior to insertion, the patient was instructed to wear the appliance late afternoon, every evening, and throughout the night while sleeping. Once or twice a week, the expansion screw was advanced by one quarter turn (0.25 mm), which is about one half the width of the periodontal space. The patient reported for clinical adjustments and observation every 3 to 4 weeks. Intraoral photographs were taken at each visit. After approximately 3 months, the patient was provided with a lower appliance of a similar design. The total active treatment time was approximately 12 months. At the end of active treatment, facial and intraoral photographs were taken, as well as a post-treatment 3-D CBCT scan. The CBCT scans were assessed for morphometric changes.

Results
Clinically, it was evident that changes occurred not only in the dental arch but also on the face (Figures 2a to 2d). These changes included an enhanced appearance of the eyes, increased symmetry of the upper lip and nose (Figure 2d), and reduction of the labiomarginal grooves on the right side of the face after treatment with the DNA appliance. Figures 3a and 3b demonstrate the widening of the upper arch, which was achieved without any reduction of tooth enamel. In addition, the lower arch increased in symmetry, and the alignment of the anterior teeth was significantly improved (Figures 4a and 4b).

Figure 1. The DNA appliance design used in this case, incorporating 3-dimensional (3-D) axial springs, Adams clasps, a midline expansion screw, a labial bow, and bilateral occlusal pads.

Skeletal changes associated with the facial changes were also assessed using 3-D morphometrics. The changes in the facial skeleton were captured graphically using pseudocolor changes (Figure 5). Superimposition of the pre- and post-treatment 3-D reconstructions indicated an increase in bone volume, extending from the zygoma and mandibular ramus region to the angle and body of the mandible, as well as across the maxillary region on the right side of the face.
Using the 3-D CBCT data, it was found that the upper airway parameters were also improved. For example, the retropalatal distance increased in the sagittal plane from approximately 3.4 mm (Figure 6a) to 5.8 mm (Figure 6b). Similarly, the retroglossal distance increased in the sagittal plane from approximately 5.9 mm (Figure 6a) to 8.6 mm (Figure 6b). These improvements in upper airway morphology were accompanied by increases in mediolateral upper airway widths (eg, from 21.3 mm to 32.1 mm retropalatal; and from 20.9 mm to 40.5 mm retroglossal). Overall, the upper airway volume increased 94% from 17 cm³ to 33 cm³.

DISCUSSION
This case report shows that craniofacial changes were achieved through the use of a nonsurgical, biomimetic, oral appliance, indicating that dentists may be able to alter craniofacial architecture using this novel protocol.
Biomimetics (or biomimicry) is the science of using natural designs or processes to resolve human problems. The idea of using dental appliances is not new; the first removable dental appliances go back to the 1880s. Kingsley⁶ reported on the treatment of oral deformities and irregularities using removable appliances. Similarly, Haupl et al⁷ employed appliance therapy, using intraoral devices. In fact, orthopedic correction of condylar hypoplasia using a functional appliance was reported,⁸ producing remarkable changes in craniofacial morphology in a patient diagnosed with hemifacial microsomia. In less severe cases, dental and orthodontic practitioners have been using functional appliances for many years with good results. Singh⁹ authored a more recent review of functional appliances.

Figure 5. The 3-D cone beam computed tomography (CBCT) scan superimposition to show skeletal changes associated with the facial changes, assessed using 3-D morphometrics. The pseudocolor changes (blue) indicate increase in bone volume, extending from the zygoma and mandibular ramus region to the angle and body of the mandible, as well as across the maxilla region on the right side of the face. The pretreatment configure is the gray color.

The DNA appliance system has been used for correction in various types of malocclusion, using the concept of epigenetic orthodontics.¹⁰ For example, Class II malocclusions have been corrected in actively growing teenagers.¹¹ For adults, other craniofacial issues have been addressed. In one young adult female, an extended history of migraine was resolved using the biomimetic approach adopted here.¹² In other adult cases, a history of moderate obstructive sleep apnea was corrected.^13-14 However, to date, there have been no reports in the dental or orthodontic literature regarding aesthetic response with the DNA appliance system.
This current report demonstrates that an oral appliance can also produce significant facial changes, with increased facial symmetry and upper airway volume, in the nongrowing adult. This notion is consistent with the spatial matrix hypothesis¹⁵ as sutures respond to functional stimuli.¹⁶ We can therefore hypothesize that altering the spatial relations in adult patients, not only children, may also produce craniofacial changes. Clinically, malocclusions often exhibit narrow maxillary and mandibular arches with crowded teeth, producing a narrow smile with dark, buccal corridors. This current case suggests that by remodeling the maxilla and mandible using a biomimetic appliance, dentists can widen the smile and recapture sufficient functional space to align teeth in adults. Simultaneously, this remodeling appears to induce a better anatomical relationship between the teeth and their surrounding structures, including the facial soft tissues and the upper airway. Currently, we are planning further studies based on a larger sample of adult patients to substantiate the preliminary findings reported here.

SUMMARY
This case report demonstrated the use of a novel, biomimetic, oral appliance (DNA appliance) that produced cosmetic facial enhancement, improved dental alignment, increased bone volume, and achieved upper aiway development without using any invasive procedures. Furthermore, this particular case demonstrated widening of the arch form and smile without reducing tooth structure. Indeed, 3-D analysis was undertaken, which localized the regions in which the changes were produced by the oral appliance to confirm the clinical findings.
It is concluded that this innovative protocol may be used in cosmetic dental practice as an alternative technique to surgery or other invasive procedures to enhance facial aesthetics and gain other beneficial functional changes.

References

1. Dastoor SF, Misch CE, Wang HL. Botulinum toxin (Botox) to enhance facial macroesthetics: a literature review. J Oral Implantol. 2007;33:164-171.
2. Gordon RW. BOTOX cosmetic for lip and perioral enhancement. Dent Today. 2009;28:94-97.
3. Rao LB, Sangur R, Pradeep S. Application of botulinum toxin type A: an arsenal in dentistry. Indian J Dent Res. 2011;22:440-445.
4. Dastoor SF, Misch CE, Wang HL. Dermal fillers for facial soft tissue augmentation. J Oral Implantol. 2007;33:191-204.
5. Mandel L, Addison S, Clark M. Buccal reaction to silicone cosmetic filler. J Am Dent Assoc. 2010;141:162-166.
6. Kingsley NW. A Treatise on Oral Deformities as a Branch of Mechanical Surgery. New York, NY: D Appleton and Co; 1880:68-88.
7. Haupl K, Grossman WJ, Clarkson P. Textbook of Functional Jaw Orthopedics. London, England: Henry Kimpton; 1952:242-282.
8. Sidiropoulou S, Antoniades K, Kolokithas G. Orthopedically induced condylar growth in a patient with hemifacial microsomia. Cleft Palate Craniofac J. 2003;40:645-650.
9. Singh GD. Epigenetic orthodontics: Developmental mechanisms of functional (formational) orthodontic appliances. Journal of the American Orthodontic Society. 2010;10:16-26.
10. Singh GD, Krumholtz JA. Epigenetic Orthodontics in Adults. Chatsworth, CA: SMILE Foundation; 2009.
11. Singh GD, Lipka G. Case report: Introducing the Wireframe DNA appliance. J Am Acad Gnathol Orthop. 2009;26:8-11.
12. Singh GD, Utama J. Effect of the DNA appliance on migraine headache: case report. Int J Orthod Milwaukee. 2013;24:45-49.
13. Singh GD, Wendling S, Chandrashekhar R. Midfacial development in adult obstructive sleep apnea. Dent Today. 2011;30:124-127.
14. Singh GD, Callister JD. Effect of a maxillary appliance in an adult with obstructive sleep apnea: a case report. Cranio. 2013;31:171-175.
15. Singh GD. On growth and treatment: the Spatial Matrix hypothesis. In: McNamara JA Jr, ed. Growth and Treatment: A Meeting of the Minds (Craniofacial Growth Series). Monograph 41. Ann Arbor, MI: Needham Press; 2004:197-239.
16. Moss ML. The functional matrix hypothesis revisited. 1. The role of mechanotransduction. Am J Orthod Dentofacial Orthop. 1997;112:8-11.

Dr. Singh was born, educated, and trained in England. He is currently president of BioModeling Solutions, LLC. He is also director of continuing education for the SMILE Foundation; a senior instructor/consultant/Fellow for the International Association for Orthodontics; academic Fellow of the World Federation of Orthodontists; and member of the American Academy of Craniofacial Pain, the American Academy of Dental Sleep Medicine, and a charter member of the Appliance Therapy Practitioners’ Association. Previously, he was a visiting professor in orthodontics (Malaysia), associate professor at the University of Puerto Rico, and an adjunct professor at Portland State University. He has been published extensively in the orthodontic and dental literature, and is coauthor of a book entitled Epigenetic Orthodontics in Adults. Dr. Singh has lectured internationally in North America, Europe, Asia, and Australia. He can be reached at drsingh@drdavesingh.com.

Disclosure: Dr. Singh is owner of BioModeling Solutions, LLC, and the DNA appliance system.

Dr. Cress received his bachelor of arts degree from Austin College in Sherman, Tex. He completed his doctorate of dental surgery from the University of Texas Health Science Center, San Antonio dental branch, and his residency in dental sleep medicine at Tufts University School of Dental Medicine in Boston. He has recently completed his residency in craniofacial pain through the American Academy of Craniofacial Pain Institute. Dr. Cress is a member of the American Academy of Dental Sleep Medicine, American Academy of Craniofacial Pain, ADA, Texas Dental Association, AGD, and the Greater Houston Dental Society. He can be reached at sam@colonydental.com.

Disclosure: Dr. Cress reports no disclosures.

INTRODUCTION
Adults comprise a large part of the population in need of orthodontic treatment to correct misalignment. While the benefits of orthodontic treatment include a healthier mouth, the most obvious is a cosmetically enhanced and more pleasant smile. However, people needing orthodontic treatment generally are more likely to suffer from or develop periodontal disease, temporomandibular joint (TMJ) disorders, headaches, and neck, shoulder, and back pain, all of which can often be avoided with orthodontic treatment.¹
Unfortunately, adult patients often express trepidation about undergoing orthodontic treatment and routinely forego this therapy because of the stigma associated with metal braces.²
The extended time frame and the embarrassing, unattractive look of metal braces many times keep patients from choosing orthodontics to enhance their smiles. As a result, the vast majority of adults and older teen patients opt out of a treatment modality that could enhance their smile and oral health. Compounding the problem is the fact that because orthodontics is a specialty, many general dentists do not feel confident offering orthodontic consultations or treatments to their patients.
As alternatives are discussed with patients, the type of treatments that are possible to create a straight-looking smile are often reviewed, including “instant” (ie, restorative) orthodontics. When educated about minimally invasive techniques, most patients would want to conserve tooth structure, rather than grind down natural dentition to place veneers and other restorations.^3,4 However, some orthodontic techniques that are more appealing to patients than braces (such as aligners) are not as predictable as expected,⁵ and lack of patient compliance may impede their success.

Short-Term Orthodontics
Short-term orthodontics is breaking down barriers between patients who could benefit from braces and the treatment itself. More patient-friendly than comprehensive orthodontics, short-term orthodontics enables general dentists to provide a treatment that is beneficial to patients who present with cosmetically driven alignment issues, rather than requiring changes in angles class. Short-term orthodontics is typically an option to meet the patient’s goals for an enhanced smile appearance as long as the jaw and mouth are fully developed and a stable and healthy occlusal foundation requiring minimal adjustments is present.^6,7
Unlike most traditional braces treatments, short-term orthodontics generates an aesthetically pleasing smile within 6 months for most patients. This adds to the concept’s already patient-friendly attributes of requiring no personal compliance on the patient’s part of adhering to schedules, as well as being both comfortable to wear and aesthetically pleasing. As a result, vanity issues associated with the appearance of metal braces are eliminated.
Additionally, while everyone has a right to basic oral healthcare and a straight, healthy smile, not everyone has the financial means to obtain their desired smile through comprehensive orthodontic treatment and cosmetic procedures. Many individuals subsequently forego oral healthcare services and live with unappealing and oftentimes damaged smiles.
Short-term orthodontics is therefore also more patient-friendly from a financial perspective, since it provides individuals who are financially challenged with the opportunity to have the smile they have always desired. Because treatment expectations and outcomes are, and always should be, thoroughly discussed, patients can make informed decisions about cost versus benefit. Short-term orthodontics emphasizes moving teeth efficiently into the appropriate position to affect a cosmetic change, rather than addressing every imperfection. By simply and effectively moving teeth into proportion to the patient’s face and stature, improvements to the overall symmetry of the smile can be made^.8 Therefore, patients are more likely to accept and dentists to recommend short-term orthodontic assistance.
Patients tend to feel a sense of relief when they wear braces. Although there is a stigma associated with metal braces, undergoing orthodontics indicates to the public that the person is making an effort to straighten hie or her teeth, and that raises ones perceived position within society.⁹

CASE REPORT
Diag is and Treatment Planning
A 44-year-old man presented with a chief complaint about the appearance of his smile (Figure 1). He developed a habit of covering his mouth with his hand when he smiled to avoid revealing the severe spacing and misalignment. Although he had wanted braces for more than 30 years, he was unable to undergo orthodontic treatment for numerous reasons, including financial limitations and the stigma associated with unaesthetic metal braces.

Figure 1. Right side view, demonstrating patient’s slightly open bite.

A thorough examination was performed. The patient was classified as having a Class I molar relationship and missing teeth Nos. 2, 4, and 15 due to decay. Additionally, tooth No. 11 erupted toward the facial/cervical area. Due to overall crowding, tooth No. 11 had always been crowded out of the arch. Teeth Nos. 8 and 9 were chipped, but had been repaired with composite bonding that had stained over time.
The patient presented with a prior understanding of his condition and knowledge of various treatment options. He had consulted with a local orthodontist about comprehensive orthodontics, but he immediately declined this option due to appearance issues and the 2- to 3-year treatment time. During his first consultation at this office, removable aligners (eg, Invisalign), a removable aesthetic appliance (eg, Snap-On Smile [DenMat]), and short-term orthodontics (eg, Six Month Smiles) were discussed as treatment alternatives.
The removable aesthetic appliance was dismissed because treatment would present complications with tooth No. 11, since that tooth and all of the rotated teeth would be difficult to cover. The patient also declined the removable aligner option based on the length of treatment time (about 2 years), as well as limitations with the device associated with erupting and rotated teeth. Additionally, the patient would require several attachments on his front teeth, which would present the same aesthetic hindrances as comprehensive orthodontics, the necessity of having to wear aligners, and a higher price fee for services.
After discussing all of these considerations, the patient elected to undergo short-term orthodontic treatment. He was thoroughly informed about the treatment relative to his expectations and diagnosis, and preferred the more permanent solution to his smile problems that this treatment would provide. The patient also appreciated the shorter treatment time, minimally invasive treatment plan, and the ability to stay within his budget. Additionally, as a businessman who spends the majority of his day face-to-face with people, the cosmetic nature of this short-term orthodontics system would allow him to undergo treatment in an unobtrusive manner.

Treatment Protocol
Systems that unite and simplify clinically proven orthodontic technologies and the science of traditional braces with the ease of use of aligners (eg, Six Month Smiles) enable general dentists to provide patient-friendly short-term orthodontic treatments. This type of treatment addresses a patient’s principal cosmetic concerns while minimizing the complexity of the braces placement process. As a result, patients can elect to undergo a minimally invasive procedure to enhance the alignment of their teeth, after which they may choose to pursue future elective cosmetic treatments such as whitening or composite bonding.¹⁰
When a well-planned, short-term orthodontics system is used, general dentists can straighten their patient’s teeth using specialized materials designed to effectively and efficiently treat cosmetic dental cases. Contributing to the patient-friendly nature of the treatment are the clear brackets and tooth-colored wires that blend with natural dentition.¹¹ The Lucid-Lok (Six Month Smiles) wires gently and consistently apply pressure to straighten and align the patient’s teeth.
To initiate treatment, impressions were taken of the patient’s upper and lower arches and models were poured. These were forwarded to the Six Month Smiles Case Processing Center. There, a bracket specialist/technician set up the case by creating a customized patient tray kit (PTK), which would be returned to the dentist to begin treatment. The PTK included bonding trays that facilitated a one-step bracket seating process. The brackets were accurately positioned into the bonding trays to ensure precise intraoral placement.
At the braces placement appointment, the patient’s teeth were etched where appropriate, rinsed, and died. The adhesive obtained from the PTK was applied to the etched teeth, and the bonding trays were seated intraorally. Once the brackets were secured (light-cured) onto the patient’s teeth, the tooth-colored wires and ties that blend with the natural teeth were attached and adjusted accordingly.¹¹

Alignment Progress
The patient returned to the office periodically for minor adjustments. After 8 weeks in the short-term orthodontic braces, tooth No. 11 had already moved quite a bit (Figures 2 and 3), and teeth Nos. 25 and 26, which had been very lingually placed, were moving facially (Figure 4). Targeted interproximal reduction was completed as needed to accommodate movement of tooth No. 11.

Figure 4. Lingually positioned teeth Nos. 25 and 26 were also moving facially at 8 weeks of treatment.	Figure 5. Left side view, taken at 10 weeks of treatment, illustrates additional movement of tooth No. 11.
Figure 6. At the 10-week follow-up, the patient expressed concerns about teeth Nos. 9 and 10 sloping upwards, which resulted from the high position of tooth No. 11.	Figure 7. After 24 weeks of treatment, a significant improvement was observed in the alignment of tooth No. 11, following use of elastics.
Figure 8. This view, captured while changing wires, demonstrates how the upper left teeth are approximating the anticipated position.	Figure 9. Upon removal of the short-term orthodontic braces, the patient was thrilled that his chief complaints had been successfully addressed.

After 10 weeks of treatment, tooth No. 11 continued to demonstrate significant movement (Figure 5). However, elastics were discussed with the patient to facilitate downward movement of this tooth into occlusion and relieve the upward sloping of teeth Nos. 9 and 10 (Figure 6). After 24 weeks in braces, and following the use of elastics from tooth No. 11, a significant improvement in tooth alignment was obvious (Figure 7).
At a later follow-up appointment to change wires, the patient’s teeth appeared to approximate their desired position on the upper left (Figure 8). At this time, the lower teeth were aligned and only required incisal shaping. However, teeth Nos. 10 and 11 were not completely in position, so it was determined that the patient would wear elastics for one more month.
At the braces removal appointment after approximately 9 months of treatment, it was apparent that the patient’s chief cosmetic complaints had been resolved (Figures 9 and 10). The patient was very pleased with the final results of his short-term orthodontic treatment, which addressed all of his primary concerns. Although his smile still presents minimal appearance issues and would not be considered perfect according to orthodontic standards, the patient’s cosmetic objectives were met. As a direct result of his new and improved smile, the patient has developed elevated self-esteem and confidence compared to his demeanor pretreatment. He has become more talkative and outgoing, and he smiles all the time (Figure 11), something he never felt able to do in public before treatment.

Figure 10. By moving tooth No. 11 incisally into alignment, the patient experienced complete relief of his intense allergies and sinus problems.	Figure 11. Post-treatment right lateral retracted view. A few months later, tooth No. 4 was restored with an implant-supported all-porcelain crown.
Figure 12. Post-treatment left lateral retracted view. Interproximal reduction was required around tooth No. 11 and the surrounding teeth, rendering its shape slightly more slender than ideal. However, the patient was opposed to any tooth extraction, requiring tooth movement into position with more aggressive interproximal reduction and rounding of the arches.	Figure 13. Our very happy and smiling patient!

It is important for patients to be fully aware that even with orthodontic treatment to correct tooth alignment, there is always the likelihood that if proper maintenance, such as wearing a retainer or mouthguard, is not strictly followed, undesirable tooth movements may occur. It is strongly recommended to note and take into consideration that teeth move and may relapse after treatment.¹² For this reason, bonded lingual retainers were placed on both the maxillary and mandibular arches (Figure 12).

DISCUSSION
Unlike traditional braces, short-term orthodontics (such as Six Month Smiles) is specifically tailored to treat and correct cosmetic cases, rendering it patient-friendly and uncomplicated for general dentists to incorporate into their practices. It is also minimally invasive. Therefore, the fear of painful and time consuming dental procedures that oftentimes impede patients from receiving orthodontic care is eliminated.
Additionally, short-term orthodontics can predictably achieve a wide range of tooth movements, including extrusions, rotations, intrusions, and various types of tipping.¹³ Successful treatment is predicated on careful case selection and on understanding the patient’s expectations for braces treatment, as well as what is possible with this treatment modality.
The vast majority of adults with malpositioned teeth are candidates for short-term orthodontic treatment which, depending upon the patient’s objectives, can most often be completed within 6 to 9 months. In this case, due to the patient’s extensive gaps between teeth, and because the natural teeth required more extensive movement to achieve alignment, the procedure took nine months to complete. The longer time frame was compounded by the patient’s choice to not remove any permanent teeth.¹⁴

CONCLUSION
The case described here has demonstrated the power and ability of dentistry to fundamentally change people’s lives by enhancing their smile. This patient’s short-term orthodontic treatment dramatically improved his appearance by achieving a smile that is considerably straighter and more aesthetically pleasing (Figure 13).
While comprehensive orthodontics remains the gold standard for addressing problems involving a patient’s entire occlusal scheme, short-term orthodontics is a patient-friendly treatment option for resolving cosmetic-related concerns involving malalignment in the anterior upper and lower teeth during the smile process.¹⁵

References

1. Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby; 2007.
2. American Academy of General Dentistry. InfoBites: Orthodontics align crooked teeth and boost self-esteem. knowyourteeth.com/infobites/abc/article/?abc=O&iid=322&aid=1301. Accessed January 24, 2013.
3. Spear FM. The esthetic correction of anterior dental mal-alignment conventional vs. instant (restorative) orthodontics. J Calif Dent Assoc. 2004;32:133-141.
4. Christensen GJ. Informing patients about treatment alternatives. J Am Dent Assoc. 1999;130:730-732.
5. Kravitz ND, Kusnoto B, BeGole E, et al. How well does Invisalign work? A prospective clinical study evaluating the efficacy of tooth movement with Invisalign. Am J Orthod Dentofacial Orthop. 2009;135:27-35.
6. Parker MW. The significance of occlusion in restorative dentistry. Dent Clin North Am. 1993;37:341-351.
7. Mount GJ, Ngo H. Minimal intervention: a new concept for operative dentistry. Quintessence Int. 2000;31:527-533.
8. Chiche GJ, Pinault A. Smile rejuvenation: a methodic approach. Pract Periodontics Aesthet Dent. 1993;5:37-44.
9. Williams AC, Shah H, Sandy JR, et al. Patients’ motivations for treatment and their experiences of orthodontic preparation for orthognathic surgery. J Orthod. 2005;32:191-202.
10. Milnar FJ. Mastering minimal intervention and discretionary esthetic procedures when placing direct composites. Pract Proced Aesthet Dent. 2005;17:428-432.
11. Swain R. The six month smiles system: Creating dramatic changes in tooth position and smile symmetry with a novel orthodontic system. Inside Dentistry. April 2012. dentalaegis.com/id/2012/04/the-six-month-smiles-system. Accessed January 24, 2013.
12. Ackerman MB, Thornton B. Posttreatment compliance with removable maxillary retention in a teenage population: a short-term randomized clinical trial. Orthodontics (Chic.). 2011;12:22-27.
13. Skidmore KJ, Brook KJ, Thomson WM, et al. Factors influencing treatment time in orthodontic patients. Am J Orthod Dentofacial Orthop. 2006;129:230-238.
14. Mavreas D, Athanasiou AE. Factors affecting the duration of orthodontic treatment: a systematic review. Eur J Orthod. 2008;30:386-395.
15. Sarver DM. Principles of cosmetic dentistry in orthodontics: Part 1. Shape and proportionality of anterior teeth. Am J Orthod Dentofacial Orthop. 2004;126:749-753.

Dr. Nauman is a general dentist in Tulsa, Okla. After graduating from the University of Nebraska College of Dentistry, she spent 9 years working part-time as an associate. Two years ago, Dr. Nauman started Glisten Dental, a practice committed to providing excellent dentistry with an emphasis on patient education, high technology, colorful and modern surroundings, and a support staff dedicated to making patients comfortable. Because short-term orthodontics is a large part of Glisten Dental, Dr. Nauman and her team are rewarded daily by seeing straight, beautiful smiles change their patients’ lives. Dr. Nauman is a member of the ADA, Oklahoma Dental Association, and Christian Dental Society. She can be reached at drangienauman@gmail.com.

Disclosure: Dr. Nauman reports no disclosures.

CASE TYPE IV: TRANSFER CASE WITH TIPPED POSTERIOR TEETH
While some believe that they can nonsurgically expand the dental arch through orthodontics in an adult patient, it has been proven that “expansion” (crown tipping in an adult) at past the age of 13 years is not significant, and it is prone to relapse.¹ Posterior crowns tip to the buccal without significant root translation resulting in an unaesthetic and unstable result also prone to gingival recession.

Figure 1. Patient first came into our office with teeth tipped outward through use of removable expansion appliances. There was sufficient space for alignment, but the roots were in unstable positions with crowns tipped to the buckle.	Figure 2. A stable result must maintain arch circumference in an adult patient with the teeth in cortical bone to prevent inward collaspe post-treatment.

Figure 3. Patient presented with narrow incisors due to previous treatment that relied too heavily upon enamel reproximation and scarificed tooth proportion and aesthetic outcome.

Patient in Figure 1 was referred by an orthodontist in Los Angeles for lingual orthodontics. He expanded her for one year with Crozat appliances, leaving sufficient space to align the teeth (Figure 1). At this point, she moved to Boston, where we commenced lingual orthodontic treatment which proceeded smoothly. Brackets were removed with an aesthetic result. However, in the months after completion, the arch form and tooth roots continued to collapse inward. Expansion had spread the teeth laterally into an unstable position outside the cortical bone. The patient needed a brief course of retreatment with enamel reproximation which yielded a far more stable result which has been maintained well (Figure 2).

CASE TYPE V: OVERUSE OF ENAMEL REPROXIMATION
While the previous case showed an under-reliance on enamel reproximation, this case shows overreliance on it. Lack of flexibility and overreliance on any one treatment modality has its perils, though. The patient in Figure 3 was looking for retreatment despite the fact that her teeth were straight. In order to achieve an ideal occlusion nonextraction by the treating orthodontist, the teeth had been interproximally reduced to the point that they were unaesthetic, lacked embrasure space, and were not self-cleansing. This resulted in unaesthetic tooth proportions and perpetually inflamed papillae. Minor alignment was done along with recontouring. The teeth were shortened to establish better proportion, and embrasure spaces were opened to allow better self-cleansing.

CASE TYPE VI: SPECIAL RETENTION NEEDS; ADULT CLASS II, DIVISION 2; LARGE DIASTEMA, SEVERE ROTATION
The Class II, Division 2 is a common type of crowding where the upper centrals tip palatally and the laterals flare labially (Figure 4). Aesthetically conspicuous, it is usually a simple case to align dentally with enamel reproximation. These patients do not usually have a profile problem needing orthognathic surgery. As they are fully grown adult patients, skeletal change and complete overjet correction is not usually possible nonsurgically, so the upper central incisors will always tend to relapse palatally. Therefore, this is an ideal case for maxillary lingual splinting of teeth Nos. 7 to 10 or teeth Nos. 6 to 11. Slight overjet allows a durable splint to be placed out of occlusion in a case type that would otherwise be very prone to relapse. Recognizing the instability of cases that have a skeletal component is essential, and this patient’s aesthetics are basically identical today to the result (Figure 5), 12 years after completion, with no noticeable relapse due to her upper and lower lingual fiber-reinforced composite splints (Ribbond).

Figure 4. Adult Class II, Division 2 is very prone to relapse.	Figure 5. Splinted result maintained well (at 12-year recall).
Figure 6. Large diastema needing fixed retention.	Figure 7. After short-term orthodontics (STO) with splinting.
Figure 8. The 3.5-year recall with fiber-reinforced composite (FRC) (Ribbond) splints.	Figure 9. Severely rotated incisor.
Figure 10. This rotation could never be maintained without a splint.	Figure 11. Four-year recall with maxillary FRC splint.

Large diastema cases (Figures 6 to 8) also have special retention needs (a maxillary splint), as do severely twisted teeth (Figures 9 and 10). Though it requires overjet be left in the final result, the maxillary splint provides excellent retention, though it can require maintenance. Removable retainers would almost surely fail to retain these particular tooth movements. However, with the maxillary splint, the excellent results were well-retained in both cases at the 3- and 4-year recalls (Figures 8 and 11). Few orthodontists finish cases with the overjet needed to allow for placement of a maxillary splint.

CASE TYPE VII: Temporomandibular Disorder
This patient was a bruxer whose crowding and anterior recession were worsened by bruxing forward, causing anterior displacement of an upper central incisor (Figure 12). As a prominent cosmetic dentist, he came to Boston for rapid cosmetic orthodontics. The alignment proceeded smoothly with one exception: I allowed the likable dentist-colleague to limit my enamel reproximation in the lower arch. Therefore, my ability to retract the lower incisors and establish sufficient overjet also became limited. Parafunction usually ceases at the beginning of orthodontic treatment, but then returns once the teeth are no longer sore. Once the parafunctional bruxing returned, the upper central (that now had been retracted back) caused a more retrusive and limiting anterior guidance on the mandible (Figure 13). The new incisal guidance brought less freedom of the mandible during bruxing, pushing it backward, so disc compression and tinnitus followed.

Figure 12. Bruxer, before STO, with protruded tooth No. 8 from bruxism.	Figure 13. Bruxer, after STO, with normal incisor occlusion.

Our typical treatment method of leaving overjet avoids any retrusive incisor contact on the mandible, and avoids TMD sequelae. The lack of tight anterior coupling in my finished orthodontic cases accounts for the fact that I rarely see TMD in my patients after STO—a remarkable statistic, especially considering occlusal change is not the primary treatment focus. One must be very cautious when leaving a case with the incisors tightly coupled together in occlusion, as any lower incisor relapse or change in jaw position forward may cause disc compression and the pain that may or may not have been poresent beforehand.

CASE TYPE VIII: LARGE TONGUE
Patients with a large tongue often have anterior spacing. The patient’s tongue in Figure 14 already fills the space available and goes to the lingual surfaces of the teeth. While the anterior spacing can be reallocated distal to the canines, the incisors cannot be retracted and maintained inside the neutral zone with long-term stability. The tongue pressure will push the teeth forward unless tongue reduction has occurred. In such cases, we always explain to our patients at the initial consult that space will be redistributed distally to maintain an incisor position that is in harmony with the tongue, instead of a retracted incisor position when the tongue will not allow them to be maintained and would cause relaspe.

CASE TYPE IX: PROTRUSION WITH UNAESTHETIC PROFILE
There is no STO solution for cases with an unaesthetic facial profile and lip incompetence. This case needed bicuspid extraction because the amount of upper incisor retraction required cannot be done with enamel reproximation alone (Figures 15 and 16).

Figure 14. Large tongue prohibited the retraction of incisors.	Figure 15. Bicuspid extraction case with lip incompetence.
Figure 16. After bicuspid extraction treatment.	Figure 17. Surgical case that requires a referral to the surgeon-specialist team.
Figure 18. Canine substitution needed for missing upper lateral incisors.	Figure 19. Final result; bonded and splinted upper canines and bicuspids without any bridgework or implants.

Even more involved, the skeletal case in Figure 17 clearly needs orthognathic surgery.

CASE TYPE X: MULTIDISCIPLINARY CASE
This case cannot be done with orthodontics alone (Figures 18 and 19). Treatment involved surgical exposure and bringing down impacted canines throughout one year (still considered STO due to the complexity of the case), as well as splinting with reshaping and bonding. Canine substitution was done for the missing upper laterals incisors. With some creative thinking, this patient avoided any bridgework or implants as this result was achieved solely with orthodontics and bonding. Most patients enjoy a result with greater simplicity, stability, and predictability, while eliminating implant surgery and minimizing treatment time and expense. This type of thinking can bring people back to dentistry, especially adult patients like this with aesthetic problems who have not sought out care sooner due to obstacles inherent in a conventional and more involved treatment plan. Patients opt out of 2-year treatment when there is a shorter plan with proven results.

CONCLUSION
As dentists, we have a myriad of responsibilities that can make dentistry complex as well as rewarding. Diagnosis and treatment planning, patient management, and retention protocol all vary with a need to understand and accommodate each patient’s teeth and character. Comprehensive 2-year orthodontics may better address more complex cases, but there is also a demand for more rapid orthodontic treatment for the typical adult cosmetic cases.
We must always remember that elective cosmetic dentistry of any type often comes with a human dimension of personal preferences that is often distinctive. These preferences must be understood, addressed, and ideally, satisfied, within the parameters of a healthy and stable long-term result.

Reference

1. Bishara SE, Jakobsen JR, Treder J, et al. Arch width changes from 6 weeks to 45 years of age. Am J Orthod Dentofacial Orthop. 1997;111:401-409.

Dr. Georgaklis is a general dentist who originated the concept of 6-month adult aesthetic orthodontics in his Boston practice. He has performed it since 1991 and has lectured to thousands of dentists on various aspects of the topic. Both instructors on the topic of 6-month orthodontics have taken his in-office over-the-shoulder course. He can be reached at (617) 277-5200 or cgeorgaklis@comcast.net.

Disclosure: Dr. Georgaklis reports no disclosures.

CASE TYPE I: BRUXERS
Severe bruxers who do not wear their nightguard often experience relapse after orthodontics. The patient in Figure 1 underwent STO for anterior space closure and achieved a nice aesthetic and occlusal result. However, retention for bruxers hinges on strict adherence to retainer wear as well as diligent nightguard use. As new abfractions are evident in the recall photo, he did not comply.
Throughout a period of 14 years post-treatment, the patient’s vertical dimension of occlusion (VDO) decreased. Two crowns were done to cover fluorosis. Although the protrusion and diastema did not significantly relapse, the deep bite returned (Figure 2). Though this may also occur in 2-year orthodontic cases, I more thoroughly emphasize strict adherence to nightguard use indefinitely in these cases. I inform bruxers that orthodontics is of minimal or no benefit if they are not prepared for a lifelong commitment to retention. Despite some relapse, he is still a satisfied patient in our practice 14 years later and fully understands the responsibility of retention lies with him through wearing his nightguard-Hawley combination at night.

Figure 1. Preoperative: Before with diastema and deep bite from bruxing.	Figure 2. Postoperative: The 14-year recall after 6-month short-term orthodontics (STO). The patient did not wear his nightguard.
Figure 3. Preoperative: Clencher before STO.	Figure 4. Postoperative: Clencher, splinted.

Similar to case 1, this patient was splinted and still experienced some relapse of her VDO at recall because of bruxism and limited nightguard wear. However, her alignment was maintained (Figures 3 and 4).
Figure 5 shows another patient who is a severe bruxer with flat plane occlusion. He experienced buccal migration of his upper first bicuspids post completion due to no nightguard wear. This occurred before postorthodontic settling took place, and articulating paper showed these bicuspids more heavily in occlusion than his molars. When he bruxed laterally, the buccal bone (which had not yet solidified) did not resist buccal tipping from the lateral forces on these teeth during parafunction.
Rarely is every tooth in complete occlusion postorthodontics, even with comprehensive treatment. Bruxers and clenchers usually experience more rapid post-treatment settling with more complete interdigitation than nonbruxers. But when the patient is a severe bruxer, selective migration may occur, especially if this is a flat plane occlusion with no cusps. This patient was rebracketed for 2 months before having a complete occlusion equilibration at the day of debracketing. Nightguard wear was strictly emphasized and the final result was stable.

CASE TYPE II: OBSESSIVE COMPULSIVE DISORDER TYPE COSMETIC PATIENTS
Another case type to watch for is the cosmetic patient who wants to dictate the treatment plan. While it is tempting to want to “please” a cosmetic patient, as it is an elective procedure after all, forging into a new area or performing a procedure with which you have less experience means less predictability in the final result. Doing this on patients who have exacting personalities and have a specific end result in mind further increases the risks involved. As with the bruxer category, patients like this can be red flags in cosmetic dentistry. These patients often start out with enthusiasm and seem to grasp the nuances of cosmetic dentistry, understanding the details of smile design. We may feel on the same page as these individuals who share our love for cosmetic excellence, and this makes dentistry fun. But when enthusiasm morphs into unrealistic expectations of perfection, and the patient cannot fully understand that there are limitations, difficulties may arise. Do we always know exactly what end result can and cannot be achieved? Are computer simulations really honest predictors of the end result, and should we depend on them to be accurate in every case? In a perfect world, we could predict all contingencies as well as the final result. But unless one has done every possible case type on every possible personality type with the various biologic limitations, there is no way anyone can predict the myriad of possibilities which may arise in every cosmetic case.

Case 1
This first case involves a simple level and alignment type orthodontic case with a slight open bite (Figure 6). Toward the end of treatment, though, the patient decided she also wanted anterior bonding to change her basic tooth shape from round to square. She brought in close-up photos of a famous American supermodel, and wanted her teeth to resemble this model’s smile. These teeth are square, slightly flared forward, and appear wider at the incisal than at the height of contour, usually the widest part of the tooth. When the patient presented for treatment, there was no indication her preferences were so specific. At this point in treatment, we are “married” to our patient, and separation is unfulfilling for both patient and dentist. After treatment, retention and incisal bonding were combined with a composite-Ribbond splint (Figure 7).³

Figure 5. Preoperative: Bruxer with flat plane occlusion.	Figure 6. Preoperative: STO with open bite.
Figure 7. Postoperative (after STO): Patient requested long square teeth like a famous supermodel she admired.	Figure 8. Preoperative (before STO): Patient recently completed Invisalign treatment in another office.
Figure 9. Postoperative to short-term lingual orthodontics with custom requests. Patient wanted his centrals to be longer and a bit more protrusive and brought in a photograph of a famous actor’s teeth to copy.	Figure 10. Preoperative: before STO.

The splint helps to support more durable lengthening of the incisal edges, often done with porcelain veneers. While the orthodontics went smoothly, the final step of aesthetic bonding and recontouring was tedious and difficult.

Case 2
This patient had not long before completed Invisalign treatment elsewhere with acceptable results, but had very specific requests and a particular mental picture of how he wanted his teeth aligned and shaped. I was hesitant to take the case, as his alignment was already fairly good (Figure 8). A chief complaint list was made at the initial consult and twice reviewed with the patient. He chose lingual braces, the most difficult to control. He was advised that we may need to do some finishing with labial brackets in the final weeks. During treatment, his requests grew even more specific and he brought numerous hand-drawn sketches and a picture of a famous American actor’s smile to copy. More frequent visits were required, but the teeth were aligned in 4 months to his specifications, like this actor’s smile, with the upper centrals slightly protruding and longer (Figure 9). The patient completed treatment very happy with the result, but it is still risky to accept this case type knowing the patient has such a specific result in mind.

Case 3
This patient had become addicted to cosmetic surgery at a young age. At the consult, he expressed his dissatisfaction with his plastic surgeon despite what seemed were good results. Because his occlusion, crowding, and tooth morphology were so unaesthetic, it seemed that significant aesthetic improvement would not be difficult (Figure 10). However, the patient had numerous specific demands, including exact measurements for the lateral incisor veneers done after Figure 11. The final results were excellent but, again, the process difficult due to specific requests.

Figure 11. After STO, but before porcelain veneers on teeth Nos. 7 and 10.	Figure 12. The patient had central incisors extracted at a young age, before conventional 2-year orthodontics.
Figure 13. After distalizing lateral incisors.	Figure 14. After retreatment with laterals brought back to mesial and 4 splinted crowns.

CASE TYPE III: PATIENT ALTERS TREATMENT PLAN
To what extent do we try to please the patient? Figure 12 shows a patient who had orthodontics at age 13 years. Due to protrusive maxillary central incisors, the orthodontist decided to extract them and move laterals into the centrals’ position. With relapse, the spacing and recession is highly conspicuous. A simple treatment plan was given to consolidate the space through space closure and to provide 4 splinted crowns. When treatment began, however, the patient decided he wanted to re-establish the space for the missing central incisors to have a natural complement of teeth. As this was a patient in his 40s, the bone was not malleable. When space was established and a temporary bridge placed (Figure 13), there was slight overjet. Although I have before left overjet to provide space for a maxillary lingual splint without patient objection, this particular patient was not comfortable with his new incisor position forward. He felt that his maxillary incisal edges were noticeable, at times touching on his lower lip, although there was no deep bite. I referred him to a board-certified prosthodontist who felt there was nothing wrong with the bridge and that he could not improve significantly on the result. After a hiatus, the decision was made to retreat the case (at no change) and follow the original plan; consolidate the incisor space, and place splinted crowns. The end result satisfied the patient, and was more aesthetic, but the circuitous route there was difficult and spanned 4.5 years (Figure 14).
Bruxers, patients with obsessive compulsive disorder, and patients who alter their treatment plan represent challenging cases even when one is prepared for them and has treated similar cases previously. This is because no 2 orthodontic cases are ever identical when one considers the complete aesthetic, biologic, and interpersonal picture. We can only diligently try to consider all contingencies.

CLOSING COMMENTS
Treating such a variety of cases makes aesthetic orthodontics fascinating. Specialty orthodontic training often has a different focus which does not always encompass the adjunctive cosmetic dimension and adult psychological aspect central to success in some of these adult cosmetic cases. Furthermore, patients do not always afford us the 2 years of treatment time often needed to cross-refer across specialties and follow the traditional channels from decades past. As we listen more to our patients, the future of adult orthodontics is finally evolving, becoming a distinct area and more integrated with cosmetic dentistry.
In part 2 of this article, I will discuss transfer cases, improper use of enamel reproximation, cases with special retention needs, temporomandibular disorder sequelae, large tongues, problem profiles, and multidisciplinary cases that have unique challenges which fall out of the norm of traditional orthodontic cases.

References

1. Georgaklis CC. Six-month adult aesthetic orthodontic treatment. Dent Today. 1999;18:110-113.
2. Sheridan JJ, Ledoux PM. Air-rotor stripping and proximal sealants. An SEM evaluation. J Clin Orthod. 1989;23:790-794.
3. Georgaklis CC. Anterior retention with a reinforced composite resin splint after cosmetic orthodontic treatment. 
4. ‘;. 2002;21:54-57.

Dr. Georgaklis is a general dentist who originated the concept of 6-month adult aesthetic orthodontics in his Boston, Mass, practice. He has performed it since 1991 and has lectured to thousands of dentists on various aspects of the topic. Both instructors on the topic of 6-month orthodontics have taken his in-office over-the-shoulder course. He can be reached at (617) 277-5200 or at cgeorgaklis@comcast.net.

Disclosure: Dr. Georgaklis reports no disclosures.