ortho international No. 1, 2016

Cover / Editorial / Content / Short-term gains… long-term problems? / “An elegant and efficient approach” / eCligner—aesthetic orthodontic appliance / Vibration therapy in orthodontics: Realising the benefits / Avoiding common problems in tooth extractions / Trial of a new rapid palatal expansion screw / From straightforward to complex cases / The power of precision / Rapid maxillary expansion: small details make the difference / Shortening treatment time by using OrthoPulse / “We will be able to treat pretty much everything in the future” / Products / Meetings - Nobel Biocare Global Symposium / International Events / Submission guidelines / Imprint

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ortho
issn 1868-3207

international magazine of

orthodontics

1

2016

practice management
Short-term gains…
long-term problems?

trends & applications

Vibration therapy in orthodontics:
Realising the benefits

industry report

From straightforward
to complex cases

Vol. 1 • Issue 1/2016

[2] =>

Welcome
to the World
of Quality Orthodontics
The right choice for products and services
A division of
GC Orthodontics Europe GmbH
Harkortstraße 2
D-58339 Breckerfeld
Tel.: +(49)2338 801-888
Fax: +(49)2338 801-877
info-de@gcorthodontics.eu
www.gcorthodontics.eu

Visit us at EOS 2016 in Stockholm
(booth #AO1:10).

[3] =>

editorial

Dear Reader,
Welcome to ortho magazine! I’m happy to announce the relaunch of the international
magazine of orthodontics, which staring from now will have a firm position in the DTI
portfolio. ortho covers the most significant developments in the field, with the intention of
providing comprehensive knowledge and information on the latest technology that can
profitably be integrated into treatment concepts. We aim to serve as an educational tool, as
well as present innovative treatment mechanisms as they are developed.

Magda Wojtkiewicz

In the past 20 years, the orthodontic industry has experienced tremendous change followed
by massive growth of the market. This expansion can be observed especially in the adult market.
Usually when people think about orthodontists they think about children wearing braces, but
nowadays it is changing. The overall number of adult patients has increased by over 20 per cent
and today one in every five orthodontic patients is an adult.
How is this trend influencing modern orthodontics? And how will it affect your dental office?
We will try to find answers to these questions in this issue of ortho magazine, inside which
you will find very well-illustrated and documented articles on clear aligners, vibration therapy,
rapid maxillary expansion (RME) as well as new product information and events previews.
Dr Luis Carrière, developer of the Carrière Motion Class III Appliance, explains advantages
of this new approach, Dr TaeWeon Kim presents possibilities of orthodontic treatment with
eCligner System, and Dr Amit Lala describes benefits which vibration therapy could bring to
orthodontics. RME screws are the main topics of two industry reports, as well as the intra-oral
photobiomodulation (PBM) which could decrease orthodontic treatment time. The interview
with with Dr Graham Gardner, President of the European Aligner Society (EAS), is also informative; he explains the principles of aligner therapy and EAS’s objectives.
I hope you will find this issue illuminating and that the knowledge you gain is applicable in
your daily practice. Enjoy reading our first issue of 2016!
Yours faithfully,

Magda Wojtkiewicz
Managing Editor

ortho
03
1
2016

[4] =>

| content

page 10

| editorial
03 Dear Reader

page 16

page 36

46 Shortening treatment time by using
OrthoPulse
Biolux Research Ltd.

Magda Wojtkiewicz, Managing Editor

| practice management
06 Short-term gains… long-term problems?
Aws Alani

| trends & applications
10 “An elegant and efficient approach”

An interview with Dr Luis Carrière, Spain, developer
of the Carriere Motion Class III Appliance

16 eCligner—aesthetic orthodontic appliance
Dr TaeWeon Kim

24 Vibration therapy in orthodontics:
Realising the benefits
Dr Amit Lala

28 Avoiding common problems in
tooth extractions
Dr Kamis Gaballah

| industry report

| feature
48 “We will be able to treat pretty much
everything in the future”

An interview with Dr Graham Gardner,
President of the European Aligner Society

| products
52 Latest technology and products information
| meetings
62 Where innovation comes to life—
Nobel Biocare Global Symposium
64 International Events
| about the publisher
65 submission guidelines
66 imprint

32 Trial of a new rapid palatal expansion screw
Drs Gabriele Galassini, Elena Marcuzzi &
Paulina Natasa

36 From straightforward to complex cases
Nimrod Tal & Lauren Flannery

40 The power of precision
Claus Schendell

42 Rapid maxillary expansion:
small details make the difference
Gabriele Scommegna

04 ortho
1 2016

Cover image courtesy of Biolux Research Ltd.
(www.bioluxresearch.com)

[5] =>

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[6] =>

| practice management successful business

© Alexis
Photo / S
huttersto
ck

Short-term gains…
long-term problems?
The emergence of STO and its future implications
in general practice
Author: Aws Alani, UK

The provision of orthodontics can be a life-changing
experience for young patients whose “crooked” teeth
can affect their confidence and self-esteem. Indeed,
where mature patients present with a history of
malalignment, equally beneficial and fulfilling results
can be achieved. In government-funded systems, patients with congenital abnormalities receive treatment that is essential to their ongoing oral health.
Restorative dentists work closely with orthodontists,
who can appreciate how small details can aid in
achieving positive restorative outcomes.

06 ortho
1 2016

As a young dentist, I corrected a tooth in crossbite
with a simple T-spring appliance. It was enjoyable
and brought a different type of delayed gradual satisfaction to the more cerebral but tenuous molar
endodontics or the more artistic and instant composite build-up. I was not a specialist, but I managed
to do some orthodontics. In contrast to my experience, general dental practitioners are now more
routinely providing tooth movement with the emergence of short-term orthodontics (STO). This has
resulted in some conjecture as to the methods of

[7] =>

successful business practice management

achieving “straighter” teeth. Indeed, some may
consider STO as an emerging entity competing
with specialist orthodontics, but should it be?
The specialist training pathway for orthodontics
involves a competitive-entry three-year full-time
course linked with the achievement of a master’s
level qualification that many may feel daunted by.
Indeed, navigating the pathway from start to finish
can be difficult academically and financially when
factoring in fees and loss of earnings during training. Once qualified, the majority of these specialists
reside, like the majority of all specialists, in the
south-east of England. With this skewed distribution of specialists and assumed need for access, it
might seem prudent for general dental practitioners
to contribute to meeting the need for orthodontics.
Indeed, the long-cited managed clinical networks
have yet to be fully realised, although all planning
and documentation related to managed clinical
networks identify general dental practitioners as integral to the function of the network. The number of
orthodontic therapists has gradually increased over
the last ten years or so since inception of the first
courses in Wales and Leeds. Therapists are allegedly
more cost-effective to train and employ in a large
orthodontic practice; however, unlike their hygiene
or therapy colleagues, they cannot practise without
a specialist’s treatment plan and supervision.
Patients who qualify for orthodontic treatment
under the UK government-funded system need to
be assessed according to the index of orthodontic
treatment need. There will be an obvious shortfall of
adults or adolescent patients with minor malocclusions who do not meet the criteria who would like
their teeth straightened. This cohort may have to
seek treatment privately from orthodontic specialists or general dental practitioners. As such, these
minor or straightforward cases may be managed in
a number of different settings utilising various
techniques with the advent of STO. This may have
resulted in some territorial paranoia between the
two camps of traditional orthodontics versus STO
systems. Conversely, it may be that differing scientific, technical and ethical ethos on managing the
same problem is the source of the debate.

Quick and easy?
Commercialisation has modified the provision of
orthodontics in the UK. Indeed, there are now orthodontic brands with courses attached and a faculty
of individuals who promote their particular product.
Companies tend to boast that their product is the
best with limited complications and treatment being low risk, predictable and easy. Somewhat sur-

prisingly, courses are being run on how to convert
patients into orthodontic clients. There are books
describing strategies on promoting and increasing
revenue. They outline detailed strategies on attracting more patients than one’s local competitor—or is
that colleague? Sounds more like capitalism than
commercialism to many interested observers.
The rapid development of STO has not escaped the
venture (or some may say vulture) capitalists. In the
same vein as DIY whitening and sports guards, one
can now have one’s teeth straightened via online
companies using products delivered by Her Majesty’s Royal Mail and so cut out the middleman (i.e. the
dentist). To my knowledge, STO has yet to make it on
to the price list of Samantha’s, a beauty salon in
Peckham.

“Orthodontics is a
complicated discipline
that is difficult to deliver
optimally and efficiently.”
What may cause fear and worry is that the provision of tooth movement set against a backdrop of a
focus on increasing revenue and patient conversion
may detract from the real reasons we are providing
the treatment. The risk and benefit of treatment
must remain balanced or be rebalanced in favour of
the patient.
The best things in life are rarely quick, easy and
without reflection. While learning or training, one
gains stature from one’s mistakes and learns by
way of osmosis from those of individuals one
hopes to emulate. Becoming an expert in many a
field r equires time, effort and experience. Orthodontics is a complicated discipline that is difficult
to deliver optimally and efficiently. Treatment
planning should be performed in person not only
to appreciate the challenges the patient presents
with but also to develop a lasting patient rapport.
Equally important, patients need to be diligent
during treatment and forever more for purposes of
retention. Is it possible that a one- or two-day
course with a treatment plan lasting half a year or
less can provide equally optimal results to a specialist orthodontist utilising traditional means?
In any case, placing a time limit on any treatment
could be considered contentious. Patients ask me all
the time ‘How long is this treatment going to take
Doc?’ I always reply ‘I’ll tell you when its finished’.
As such I am rarely wrong.

ortho
07
1
2016

[8] =>

| practice management successful business
Advertising cosmetic treatments the
fair dinkum way
The Australian health ministry recently examined
the provision of cosmetic procedures and in particular the modes of promoting the treatments. The
working group found that advertising and promotion more often than not focused on the benefits to
the consumer, downplaying or not always mentioning risks. The group went on to identify advertising practices that were not driven by medical
need and where there was significant opportunity
for financial gain by those promoting these. They
identified the need to regulate promotion and advertising ethically with factual, easily understood
information from a source that is independent of
practitioners and promoters. This is unfortunately
not always readily available. In some Australian jurisdictions, there are specific guidelines that need
to be adhered to for promotion of cosmetic treatments and they specifically cover before and after
treatment adverts, which we know in the UK is a
popular practice among the cosmetically driven.
This is commonly one ideal, perfect case showcased
on the front end of the practice website with no
mention of any problems, either acute or chronic.
Another aspect of the report detailed prohibition of
time-limited offers or inducing potential customers through free consultations for the purposes of
treatment uptake. The latter is something that has
seen STO promoted by way of voucher deals on the
Internet or via smartphone applications. Others
may consider such a practice as loss leading; one
could ask who is losing and who is gaining and at
what price?
One important aspect of the report identified
the wider social impact of cosmetic procedures in
that people may become increasingly dissatisfied
with themselves and their appearance, culminating in deeper concerns for the person and reducing scope for individuality. Many dentists throughout the country may have a slipped contact here,
a rotation there or a space distal to a canine who
are unlikely to be waiting in earnest for the next
voucher deal alert on their iPhones. Inducing misgivings or raising concerns about the patient’s
tooth position where the teeth are otherwise
healthy and the patient presents with no concerns
could be considered unethical and worryingly dishonourable.

Relapse of confidence
In a recent publication from an indemnity provider, orthodontics was identified as an emerging
area for claims against their clients. This is likely to
be the tip of the iceberg, whose size will probably

08 ortho
1 2016

continually grow as more and more orthodontics
is provided and the repercussions of which may
only become apparent gradually in the future.
In the now highly litigious arena of UK dentistry,
the failure of orthodontic treatment against the
backdrop of Montgomery v. Lanarkshire Health
Board is likely to result in increased litigation. The
movement of teeth into what the patient and the
dentist feel is the correct position may be possible
in the short term, but in the long term complications may arise owing to a variety of soft- and
hard-tissue factors that cannot accommodate
this new and supposedly “right” position. Indeed,
orthodontics requires the appreciation of detail
where symmetry and alignment are “king”, but
long-term stability is the likely “empress”. Relapse
of position is a common complaint and where patients have paid handsomely for a result they may
have been happy with at the time of the cheque
clearing, over time tiny tooth shuffles can result in
disproportionate and vehement dissatisfaction.
Where teeth are moved indiscriminately, recession in the labial segment is a complication difficult to explain and remedy in the high lip line of a
conscientious and ambitious corporate female
patient. Indeed, more haste, less speed may result
in a case being etched longer in the memory of the
patient and the clinician for the wrong reasons.

Clear steps to b usiness building
A cornerstone of a successful business is the repeat customer who values the dentist and his or
her service and returns with no qualms or mis
givings about what the dentist feels should be provided. A successful business relies on patients returning in the long term owing to their positive
experiences. Focusing on short-term gains without due consideration of quality or reliability of the
treatment provided has potential repercussions
for patients, the business of dentistry and perception of the profession._

contact
Aws Alani is a Consultant in
Restorative Dentistry at Kings
College Hospital in London, UK,
and a lead clinician for the
management of congenital
abnormalities.
He can be contacted at
awsalani@hotmail.com.

[9] =>

[10] =>

| trends & applications Carriere Class III Motion Appliance

Fig. 1

“An elegant and
efficient approach”
An interview with Dr Luis Carrière, Spain, developer of the Carriere MotionTM Class III Appliance

Fig. 1: Carriere Motion™
Class III Appliance.

Dr Carrière, how long has the Motion appliance for
Class III malocclusions been on the market?
We presented the appliance for the first time at the
American Association of Orthodontists meeting in
2015. The approach is not entirely new and we have
been working on it for a couple of years. The Class II

Dr Luis Carrière creator of the newly
developed Motion™ Class III Appliance.

appliance was invented for Class II cases, but many
participants in several courses I taught on Class II, especially in Asia, asked whether it could also be used in
Class III cases. In response to this, we decided to explore this to see if it was a good option. The results we
achieved with the use of the Carriere Motion Class II
Appliance in Class III cases were amazing.
This made us realise that this appliance was really
changing the relation between the mandible and the
maxilla, harmonising soft tissue and balancing the
patient’s face. We were completely surprised by the
fantastic facial outcomes that we achieved with this

10 ortho
1 2016

minimal approach. We thus decided to create a special
design according to the needs of the mandible, the
Carriere Motion Class III Appliance.
Could you please describe in short the design fea
tures of the Carriere Motion Class III Appliance?
Why does it only have a simple molar bonding pad
with a small step in the arm and why did you aban
don the joint design you have with the Class II
Motion Appliance (rotation of the molar)?
If we look at the occlusion of the lower arch in relation to the upper, normally there is an inclination of
the posterior segments owing to the fact that the
buccal side of the mandibular molars should fit between the buccal and the lingual aspects of the maxillary ones. This means that the design of the traditional Class II pad ball is too bulky. Often, it can
interfere with the occlusion at the start of bonding, so
we decided to create a flat surface on the posterior
segment in order to avoid unnecessary collisions in
Class III mandibular positioning with the appliance.
What we have created is a design that is very clean and
simple with only those features that are needed. We
have also adapted it to the requirements of Class III
malocclusions. While we used Motion Class II Appliances in Class III patients initially, we needed to create
something that was really suited to Class III cases. We
achieved this by flattening the profile, which is now
very slim and straightforward.
It is very important to understand that in 95 %
or more of our fixed cases, we start treatment with
the Carriere Motion Appliance, which is not only restricted to Class II or III malocclusions but also extremely useful for those cases in which we have minor
crowding. We need to open limited space between the

[11] =>

Carriere Class III Motion Appliance trends & applications

maxillary or the mandibular incisors in order to easily
align the maxillary teeth or the mandibular anterior
teeth without protrusion while accomplishing what
we term a “Super Class I posterior occlusion”. For me,
this is an elegant and efficient approach to cases that
dramatically reduces the period for which brackets
are worn by our patients. Reducing the time for which
the patient has to wear brackets is a very important
factor for many patients nowadays.

Fig. 2b

With clear systems like invesalign this appliance
works amazingly well for simplifying treatment and
dramatically shortening the aligner period. This way,
many complex Class II or III cases can easily be resolved with Invisalign Lite treatment with less than
fourteen aligners. This also makes treatment cheaper
for patients and boosts the reputation of clinicians,
as they are able to treat complex cases using very
simple procedures.
The combination of the Motion appliance with our
new passive self-ligating bracket Carriere SLX and
archwire sequence truly makes complex treatment
simpler while creating a dynamic and efficient scenario in our treatments. We are very pleased with
the new Carriere SLX. Technically speaking, it was a
challenge, as we needed to create a masterpiece of
precision. Our engineers did their best work and we
achieved the highest level of technical bracket outcomes. It is a real game-changer.
How many cases have been treated with the appli
ance so far?
In our office, around 100 cases have already been
treated with the Motion Class III Appliance. It is astonishing to see the extraordinary change to the
patient’s face every time, changes that one could
imagine have been accomplished surgically, yet
were achieved without a single extraction. I think the
reason for this effect is the balanced combination of
distalisation of the mandibular posterior segments,

Fig. 2a

change of the posterior occlusal plane, and anticlockwise rotation of the mandible that completely
changes the relation between the mandible and the
maxilla. Distalisation in the mandible is extremely
fast and efficient mainly because there is an almost
empty channel between the external and internal
cortical bone. That is the reason we need very low
force elastics in terms of traction. We only use 6 oz,
¼ inch, and we normally never use 8 oz in Class III
cases, which is what we normally use in Class II
cases.

Figs. 2a & b: Carriere Motion™ Class III
Appliance with new Pad-Lock™ Base (a).

Looking at the occlusal plane, in Class III cases,
we intrude the mandibular molars with the Motion
appliance and extrude the canines. This intrusion
of molars and extrusion of canines is necessary in
Class III cases to change the occlusal plane. This way,
we bring the mandible into a better functional and
aesthetic position. The change between the mandible and the maxilla that occurs in Class II and III
cases is the main reason that we renamed the appliance from Distalizer to Motion. Not everything can
be attributed only to distalisation.
The Carriere Motion Appliance changes the relation between the mandible and the maxilla to some
extent by altering the posterior occlusal plane,
thereby moving the mandible and the maxilla into
a better functional position while balancing the
face in Class II and III cases.

Fig. 3: Designed to be minimally
invasive, the appliance is intended to
treat Class III malocclusions without
extractions, orthognathic surgery,
or facemasks.

Fig. 3

ortho
11
1
2016

[12] =>

| trends & applications Carriere Class III Motion Appliance
Figs. 4a & b: Patient before (a) and
after (b) 14-month of treatment.
Figs. 5a–c: Initial intra-oral shot (a),
after one month of treatment with
Motion™ Class III Appliance
(Fig. 5b shows the transparent
prototype, which is not yet available),
final treatment outcome
in 14-month follow-up.
Fig. 5a

Fig. 4a

Fig. 5b

Fig. 4b

Figs. 6a & b: Patient before (a) and
after (b) 3-month of treatment with
Motion™ Class III Appliance (b).
Fig. 7: Initial intra-oral shot.

Fig. 6a

In retrognathic Class II patients, we combine maxillary distalisation, controlled maxillary molar distal
rotation, and uprighting with mandibular repositioning for a better functional relation, giving stability to the case while balancing the position of
the temporomandibular joint (TMJ) anatomical
structures and harmonising the soft-tissue facial
aesthetics. In Class III patients, we promote posterior mandible repositioning, changing the posterior occlusal plane, combined with distalisation of
the posterior segments from the canine to the mo-

Fig. 6b

12 ortho
1 2016

Fig. 5c

Fig. 7

lars. This approach is often combined with a certain
upper arch development with the Carriere SLX passive system to compensate for the typical premaxillary hypoplasia related to this type of malocclusion. Our main objective is to establish a stable and
solid occlusion while balancing the patient’s face.
Have there also been cases in which the Class III
malocclusion could not be corrected? Have you
observed any TMJ problems during Class III treat
ment?

[13] =>

Carriere Class III Motion Appliance trends & applications

Fig. 8: Initial profile shot (a) and front
shot (b) of patient with mixed dentition.
Figs. 9a–c: Initial intra-oral shot with
integrated Motion™ Class III Appliance.

Fig. 9a

Fig. 8a

Fig. 9b

Fig. 8b

We are normally confronted with two types of
Class III patients, dental and skeletal Class III patients. The Motion Class III Appliance is a treatment option for both. Skeletal discrepancies are
normally treated with a combination of surgery
and orthodontics. Many patients reject the option of maxillofacial surgery for many reasons
however and remain as they are.
With this new approach, we can provide a minimally invasive treatment alternative to change
their decision and provide them with a substantial facial change that still maintains their facial
features.
We do not change the patient’s face completely, but we move the features into a more
aesthetically pleasing position. We seek to
achieve facial harmony, bringing self-confidence to the patient through compensated occlusion, facial improvement and spiritual equilibrium.
No TMJ problems have been found at this point
and not a single patient has had any problem or
symptomatology in the TMJ with this approach.

Fig. 9c

In many cases, Class III cases show an additional
functional shift of the mandible. While balancing
the occlusion, we balance the TMJ anatomical structural and functional relations. This achieves harmony in the area.
Are there any studies that have shown the propor
tion of the mesialisation effect in the upper jaw
and of the distalisation effect in the lower jaw in
the total correction of Class III cases?
This is a relatively new approach. We have conducted no studies at this point, but in r elation to the
effect of the Carriere Motion Class II Appliance, together with Prof. James McNamara from University
of Michigan and Prof. Lorenzo Franchi from University of Florence, we are studying our records in order
to determine answers to this. They are tracing our
cases to establish what is going on. Results are expected very soon.
We have observed clinically good and stable occlusions over many years. For example, you can see
in my lectures several cases that have been out of
retention for more than ten years and are completely stable. What we need is an explanation for
the experts.

ortho
13
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2016

[14] =>

| trends & applications Carriere Class III Motion Appliance
Fig. 10: Treatment outcome of
Motion™ Class III Appliance in
5-month follow-up.
Fig. 11: Profile shot in 5-month
follow-up.

Fig. 10

What force elastics do you recommend for chil
dren and adults, and what is the recommended
wearing time?
Wearing time of elastics with the Motion appliance
is 24 hours normally, except for eating. Fresh elastics
are required after each meal. In Class III cases, there
is a channel between the external and internal cortical
bone in the sagittal direction, from mesial to distal.
There is no resistance, so substantial force is not required. Instead, we only use 6 oz elastics.
In mixed dentition cases, such as those of 7-yearolds in which we place a Motion Class III Appliance
from the mandibular first molar to the mandibular
canine, we slightly minimise the force. For 4 oz, ¼ inch
will suffice. We can increase this to up to 6 oz, ¼ inch,
if required. With this technology, significant changes
to the patient’s face are achieved, resulting in a beautiful balance. This occurs in Class II and III patients
with mixed dentition. You may ask why that is. The
answer is that we change the posterior occlusal plane
and stimulate the orthopaedic effect in a new functional relation. I think this is key.

Fig. 11

What degree of dental Class III malocclusion can
be corrected with the appliance in children?
We can completely transform the scenario by controlling the posterior occlusal planes and changing
the relation between the mandible and the maxilla.
There are things that we cannot change in our patients, such as the genetic capacity of the patient to
grow. What we can do from our side is everything to
direct the growth, to modify the position of the structures and to bring structures into another position in
order to try to modify the direction and to change the
scenario completely in a way that we really ought to.
To what degree can a dental Class III malocclusion
in adults be corrected with the appliance?
We can completely change full-step Class III cases
in adult patients. We treat patients of all ages with this
system, from teenagers to 60-year-olds. Skeletal repositioning does not mean skeletal changes but a
skeletal repositioning of the mandible in relation to
the maxilla, as the mandible, specifically the TMJ, is a
dynamic anatomical structure. It is very important
that we balance that and bring it into a better position.

Figs. 12a & b: Profile shot before (a)
and after (b) 10 months of treatment
with Motion™ Class III Appliance.

Fig. 12a

14 ortho
1 2016

Fig. 12b

[15] =>

Carriere Class III Motion Appliance trends & applications

The changes we can achieve in adult cases are amazing. It is a great alternative to surgery in adult cases
and something that is going to establish a new treatment option for Class III patients.
You call your new series of lectures “facially driven
treatment for Class II and III”. What are your key
facts in this matter, and why should the facial, ske
letal and dental factors not be isolated during
treatment?
In orthodontics, we focus on good occlusion of the
molars and the canines, looking out for midline correction, overbite, overjet and whether there are too many
teeth. The patient’s face, teeth and bone position have
to be correctly adjusted and balanced. The patient has
to be left with an attractive face, as well as facial proportions and relations. We should never forget that
behind the face there is a human being who wants to
be successful in life, form natural social relationships
and have the opportunity to establish a relationship
with the person he or she has fallen in love with. We as
orthodontists are fully responsible for the patient’s
face and this is very important to consider.
The Carriere system is all about this and together
with Henry Schein Orthodontics worldwide we are
trying to spread this message. We, the orthodontists,
are able to manage the patient’s soft-tissue profile in
a positive way. How do we do that? Instead of using
synthetic material like an aesthetic surgeon, we concentrate on bone and teeth and bring the soft tissue
into a better and more natural position. We are also
able to balance the relation between the mandible
and the maxilla. By balancing the patient’s face, we
are also balancing his or her life, bringing him or her
self-confidence and restoring happiness.
However, we could also totally ruin the patient’s life
by extracting teeth unnecessarily. I am convinced that
nowadays we cannot consider orthodontics only as
treatment of the teeth. Our patients are human beings
and we have to give recognition to that.
With the Carriere system, the M
otion appliance, the
Carriere SLX bracket, the wire sequence, respect for
the tissue and the physiology of the orthodontic
movement, and considering the patient’s face, we aim
to benefit our patients. Many profiles have been affected in the past, so our objective is to create tools to
be added to the orthodontic armamentarium that
help us in this direction.
So you are saying that the orthodontist should
place much more emphasis on harmony of the pa
tient’s face.
The orthodontist is responsible for the patient’s
face. In my understanding of the specialty, he or she
has to be an e xpert on moving teeth into the correct

Fig. 13a

Fig. 13b

position, as well as on balancing profiles. He or she is
responsible for the h armonisation of the soft-tissue
and, if necessary, for sculpting the lips with dermal
fillers. Nobody understands better than an orthodontist the anatomy and proportionality of the lips.
Orthodontists also have to be experts on the use of
Botox for excessive gingival display in those patients
with a particularly gummy smile, blocking the levator
labii superioris alaeque nasi muscle to retain the
correct arch for a beautiful smile.

Figs. 13a & b: Initial intra-oral shot
with integrated Motion™ Class III
Appliance (a) and after (b) 5 months of
treatment.

However, we are not only responsible for the face.
I think we also have to train society on the correct way
to gain a beautiful facial appearance. Instead of seeking treatment from an aesthetic surgeon, they would
do better to visit an orthodontist. He or she will be able
to give them a natural and elegant aesthetic outcome,
including an attractive facial profile. If they are not
satisfied, they can always visit an aesthetic surgeon
later.
If society comprehends the importance of orthodontics for the face, far more patients will opt for
orthodontic treatment. That is why we have to start
upgrading our specialty. Orthodontics is all about
aesthetics, art and science.
Thank you very much for the interview.

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| trends & applications clear aligners

eCligner—aesthetic
orthodontic appliance
Author: Dr TaeWeon Kim, Republic of Korea

Fig. 1

Fig. 2

Fig. 1: eCligner transparent
orthodontic appliance.
Fig. 2: eCligner covers gingival tissue
for gingival stimulation, material
elasticity and comfortable fitting.
Fig. 3: eCligner wearing, easy to take
out by patient.

Fig. 4: CAPRO (IV-Tech, Korea)
programme for handmade Clear
Aligner, overlap two photos to check
the movement range in 2-D.
Fig. 5: Handmade Clear Aligner.

Fig. 4

Fig. 3

Over the last two decades, transparent removable
orthodontic appliances have been developed to treat
patients who desire a more aesthetic and comfortable treatment option compared to traditional metal
braces. There have been many published journal articles declaring the effectiveness of clear appliances,
and one of the major advantages of these appliances
is the patient’s ability to remove them for eating,
brushing, and other reasons.
The eCligner System is a clear plastic removable
orthodontic appliance produced by a vacuum former. It is made of non-toxic and biologically acceptable PET-G material, similar to PET milk bottles and
elastics. In crowding cases of 2–3 mm, orthodontic
treatment with eCligner clear aligners can be as
short as 4–5 months (Figs.1–3).

Fig. 5

16 ortho
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Development of Clear Aligners
and the eCligner System
In late autumn of 1998, the inspiration for moving
teeth with transparent removable orthodontic appliances came to me while I was observing soap
bubbles in my bathroom. I successfully started using
these appliances to treat simple relapse cases and
named them Clear Aligners. Although several appliance companies use the term ‘clear aligner’, it
was the name I originally created for marketing this
technology worldwide.
Making clear aligners in the laboratory requires
precise tooth movement control in the model set-up.
CAPRO (IV-Tech, Korea) software was used to overlap
two digital photos for checking the range of move-

[17] =>

clear aligners trends & applications

Fig. 6

Fig. 8

Fig. 7

Fig. 9

Fig. 10

|

Fig. 6: 3-D eCligner programme
enables precision digital tooth
movement in full 3-D movement
control. Each tooth segment is
separated and patterned in
hexahedron, controlled by adjustable
CR (centre of rotation) point.
Fig. 7: eCligner diagnostic data for
multitasking function, simulation for
facial profile change.
Fig. 8: Multi-overlapping
(superimposition) among each
3-D digital set-up model enables
measuring the distance and angle
directly on the monitor. Each tooth
shows current torque and angulation
as to progress. Also it is possible to
make animation function to compare
each movement pattern. Colour and
tone change function is helpful to
recognise complicated tooth
movement among the steps.
Fig. 9: Doctor view
(eCligner Dr Program).

Fig. 10: Various print function, photo
galleries. Model analysis data is useful
to determine the amount of stripping.
Fig. 11: eCligner diagnostic data,
cephalo analysis (Tweed, Ricketts,
Jarabak, Grummon), P-A view
analysis.

ment for each tooth. Using a heat-generated vacuum
former and 0.5 mm, 0.62 mm, and 0.75 mm laminate
foil, three thicknesses of aligners (soft, medium, and
hard) were created for each movement or ‘step’ of
treatment. Starting with the soft, then medium, and
then hard, each aligner is worn for one week before
moving on to the next step (Figs. 4 & 5).
As effective as handmade aligners are, there are
limits in the clinical application. The quality of the
aligner depends upon the expertise of the technician,
even using technology like the CAPRO software. Some
of the limitations include the tendency for tooth
necrosis due to heavy orthodontic forces, as well as
inefficiencies in tooth movement or misdirection. To
overcome these challenges, it was necessary to de-

Fig. 11

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[18] =>

| trends & applications clear aligners

Fig. 12

Fig. 13

Fig. 14

Fig. 15

Fig. 16a

Fig. 16b

Fig. 17

Fig. 18

18 ortho
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[19] =>

clear aligners trends & applications

Fig. 19

velop new eCligner software utilising a 3-D CAD/CAM
system. This system incorporates the same basic
principles as handmade clear aligners with the added
benefits of improved control over tooth movement,
digital diagnosis and treatment planning, as well as
consistency in estimating treatment times. It also allows for better patient communication and solutions
for lost/broken aligners or relapses. By developing this
advanced software in 2009, the eCligner System gained
significant clinical enhancements (Figs.6–11).

Mechanics of the eCligner
The eCligner System produces aligners from 3-D-
printed resin models, which are created using the
eCligner treatment planning software. Each model
represents a step and is used to create three aligners
of increasing thickness (soft, medium, and hard). The
patient wears each aligner for 1 week until that step is
complete and then moves on to the next step (3 weeks

in total). eCligner aligners are worn for 17 hours a day
and removed when eating or when drinking hot drinks.
The Treatment Plan is a guide for the entire process and
includes estimated treatment times, expected results,
profile changes, and the amount and location of IPR
(stripping) required. The Treatment Plan can also be
used to evaluate extraction or non-extraction options
in borderline cases. eCligner aligners are a comfortable
fit and the increasing thickness helps promote gradual
tooth movement, thus avoiding pain or irritation of
the periodontal ligament tissue (Figs.12–18).

Adult patients
For adult patients, aligners should be worn 17 hours
every day except during mealtimes or when drinking
hot drinks. Patients must wear the aligner each night
and clean the aligner with a toothbrush daily. eCligner
aligners can be used to create space for prosthodontic implants or extrusion for periodontal purposes.

Fig. 12: eCligner Treatment Plan,
provides summarised data for
expected result, treatment time, costs,
movement pattern in each set-up and
amount of stripping as well profile
changes.
Fig. 13: In borderline cases,
eCligner provides two Treatment Plans,
extraction and non-extraction,
to compare the difference and consult
with patient.
Fig. 14: Schematic view for eCligner
treatment progress.
Fig. 15: eCligner supplies aligner and
resin model.
Figs. 16a & b: Digital made set-up
data in treatment plan for both upper
and lower arch.
Fig. 17: eCligner wear.
Fig. 18: 2-D fine element experiment
study resulted in 150 grams generated
from 1 mm tooth movement on
0.75 mm thickness TuPan. eCligner is
able to move the target tooth 1 mm per
month. Because it has 3 different
thickness aligners to create optimum
force from light force progressively.

Fig. 19: Crowding case treatment
progress. Smile has been improved
as to corrected incisor position.
Fig. 20: Before: Adolescent patient
showed lingually erupted lateral
incisor, has been treated in a short
term (5 months of night time wear).
Fig. 21: After: Newly positioned lateral
incisor. It is not necessary to continue
the orthodontic treatment at this stage.
It is recommended to let the patient
have natural eruption.

Fig. 20

Fig. 21

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| trends & applications clear aligners

Fig. 22

Fig. 23

Fig. 24

Fig. 25

Fig. 26

Fig. 27

Fig. 28

Fig. 29

Fig. 22: Before: Crowding case
(upper jaw).
Fig. 23: Expansion movement was
designed to create a space on upper
anterior area.
Fig. 24: In progress.
Fig. 25: Final result.
Fig. 26: Before: Crowding case
(lower jaw).
Fig. 27: Anterior expansion and
posterior distal movement.
Fig. 28: In progress.
Fig. 29: Final result. Anterior and
posterior alignment have been
improved.

3-D simulations within the programme can enhance
treatment acceptance by the patient (Fig.19).

Adolescent patients
Treatment with eCligner aligners is possible with
children under 14 years of age for the purpose of
interceptive orthodontic treatment. The eCligner
System can be used for space maintenance, space
creation, eruption guidance, and growth control.
Children wear eCligner aligners for only 8–10 hours
daily and only at night. Thus, the eCligner System
does not disrupt daily routines and takes advantage
of peak growth hormone secretion during the midnight hours for maximum effectiveness (Figs. 20 & 21).

Fig. 30

Fig. 31

Fig. 32

Fig. 33

Fig. 34

Fig. 35

20 ortho
1 2016

eCligner applications
The eCligner System is effective for minor
tooth movement, crowding and spacing, and for
prosthodontic or periodontal treatment. It is also
effective for retaining the arch after orthodontic
treatment.
Examples of eClinger applications:
1. Minor crowding (Figs. 22–29)
2. Spacing (Figs. 30 & 31)
3. Intrusion (Figs. 32 & 33)
4. Extrusion for detailing & occlusal seating (Figs. 34
& 35)

[21] =>

clear aligners trends & applications

Fig. 36

Fig. 37

Fig. 38

Fig. 39

Fig. 40

Fig. 41

|

Fig. 30: Spacing case (18/M) –
Before and after.
Fig. 31: Spacing case (59/M) –
Before and after 7 months treatment.
Fig. 32: Intrusion force vector is to
improve overbite situation.
Before and after.
Fig. 33: Figures show improved smile.
Notice the upper and lower incisor
relationship. Before and after.
Fig. 34: Before: Open bite case.
Fig. 35: After: Corrected by Cow-catch
(extrusion movement for finishing and
detailing)
Fig. 36: Before: Ectopic erupted
canine (14/M). It deteriorated patient’s
pronunciation.
Fig. 37: After: Night time wear
corrected crowding as well as
improved pronunciation.
Fig. 38: Before: Crowding case.
Fig. 39: After: Expansion procedure
improved the anterior crowding.
Fig. 40: Before: Relapse case on
extracted area both left and right side.
Fig. 41: After: 3 steps of eCligner
corrected relapsed space and minor
crowding.
Fig. 42: Insufficient space for
prosthodontic implant on first bicuspid
area. Anterior spacing was shown.
Before and after.
Fig. 43: The spaces (first molars) have
been regained by uprighting procedure
for implant and anterior spacing
problem, corrected. Before and after.

Fig. 42

Fig. 43

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[22] =>

| trends & applications clear aligners

Fig. 44

Fig. 45

Fig. 46

Fig. 44: eCligner goal is to improve
patient smile view throughout the
treatment. Ideal and esthetic incisor
position and relationship lead to
change in the smile. It must be
considered before eCligner treatment
to determine the treatment goal.
Before and after.
Fig. 45: Before: Gummy smile (20/F).
Fig. 46: After: Improved smile. Incisor
position and relationship were
improved with stripping and intrusion
procedure.
Fig. 47: Whitening tray from
each set-up model. Orthodontic
treatment and whitening treatment
simultaneously.

5. Children case (Figs. 36 & 37)
6. Expansion case (Figs. 38 & 39)
7. Relapse treatment (Figs. 40 & 41)
8. For prosthodontic needs (Figs. 42 & 43)
9. For aesthetic smile (Figs. 44–46)
10. Combination with whitening treatment (Fig.47)

How to start
1. Register as a provider via the website
2. Upload patient info and photos
3. Submit PVS impressions or an intraoral scan
4. Receive and review the Treatment Plan
5. Consult with the patient using 3-D simulations
6. Accept the case
7. Receive the eCligner aligners and resin models
(Figs. 48–50)

Fig. 48

Fig. 48: eCligner website
(www.ecligner.com).
Fig. 49: Schematic process view
‘How to Order’.
Fig. 50: Treatment progress view.
3-D digital progress (set-up) was
established before eCligner treatment.

22 ortho
1 2016

Fig. 49

Fig. 47

Patient management
Confirm the proper fit of the current aligner
when the patient visits. If not fully fitting, the patient needs more time to wear the current aligner
(Figs. 51 & 52).

Solution for lost/damaged aligners and
relapse
The eCligner System provides all the aligners and
resin models. If the patient has lost or damaged
aligners, simply use the resin models to create replacement aligners. If the patient stops wearing
the aligners, find the resin model that matches the
current arch form and remake the required aligners
to restart treatment. For relapses after treatment,

Fig. 50

[23] =>

clear aligners trends & applications

Fig. 51

Fig. 52

Fig. 53

Fig. 54

find the resin model that matches the patient’s present arch form and create all the aligners from that
step to the final step. It is recommended to show the
full series of resin models to the patient to demon-

strate the entire process before starting treatment
(Figs. 53 & 54).

Retention
For the first year after orthodontic treatment, the
patient must wear the retainer every night. After the
first year, 3 nights per week is sufficient to prevent
relapse. Thereafter, the patient must wear the retainer at least 1 night per week. The retainer should
be replaced every year at the patient’s annual visit
(Fig. 55)._

Fig. 51: Check point: notice the
transparency and eCligner fitting
before and after. It depends on patient
cooperation.
Fig. 52: High transparency and just
fitting shows the sign, previous good
cooperation. Upon patient wearing
time every day, optimal progress leads
to final planned result.
Fig. 53: Check point: keep watching
patient handling the eCligner. It is
helpful to instruct the patient on how to
insert or take out using the aligner tool.
Fig. 54: Resin models are useful
create aligners when troubleshooting.
Fig. 55: Removable eCligner retainer
combined with fixed retainer. eCligner
retainer does not always accompany
the fixed retainer.

eClinger is a registered trade mark of
eClear International Co. Ltd. all rights
reserved.

about

Fig. 55

Dr TaeWeon Kim DDS, MSD, PhD, graduated from the YonSei
University Faculty of Dentistry in 1988, and completed his MSD and
Doctorate in the same university in 1991. He served as a faculty
member in the Tokyo Faculty of Dentistry in Japan between 1994
and 1995, and held office as the Head of the Department of
Orthodontics in the Ewha Womans University between 1995 and
1996. Since 1996, he has had his own private practice and
research centre.
In 2001, he received his PhD from the Showa University in Japan.
Currently Dr Kim is the President of World Federation of Aligner Orthodontics (WFAO) and a
honorary Professor in Binzou Medical College in China.
Dr Kim has been a pioneer in orthodontic treatment systems with transparent removable
aligners known as Clear Aligners since 1998. He has made significant contributions to
orthodontics with a new concept envisaging 3-D treatment planning and the digital production of clear aligners at three different levels of thickness using very sensitive technology.
Dr Kim has presented at numerous conferences across the world on lingual orthodontics,
micro implants and eCligner, and provides courses on these subjects at an international
level. He is an author of numerous articles and books.

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| trends & applications vibration therapy

Vibration therapy in orthodontics:
Realising the benefits
Author: Dr Amit Lala, USA

Introduction to vibration therapy–
multiple potential benefits
Accelerated orthodontics and vibration therapy
to fast track orthodontic tooth movement (OTM)
have been hotly debated topics in the orthodontic
industry in recent years. Periodontally Accelerated
Osteogenic Orthodontics (PAOO) techniques such
as osteotomy, open flap corticotomy, and piezocision have been shown to decrease treatment time.1
Unfortunately, these classical approaches have
had limited patient acceptance because of their invasiveness and side effects.2 In the last several years,
micro-osteoperforation, which takes advantage of
the same biological regional acceleratory phenomenon as these classical techniques, has been gaining
rapid clinical adoption because of the simplicity of
its chairside microinvasive nature.3
There is also growing evidence that the application of mechanical energy-based therapies such as
vibration can stimulate and accelerate bone formation and possibly bone remodelling.4–7 Orthodontic
tooth movement, caused by the application of light
continuous forces that induce bone formation and
remodelling, could logically be accelerated by the
application of vibrational force, with the benefit of
reducing the overall treatment time. Since 2008,
AcceleDent (OrthoAccel Technologies) has offered
a daily use vibration device, offering the promise of
accelerated orthodontic treatment based on delivering mechanical stimulation to the dentition. At
this point, research on the efficacy of this device in
accelerating OTM has been mixed, and clinicians debate its value.
The debate on vibration therapy as it applies to
accelerated orthodontics in general, and the effectiveness of the AcceleDent device specifically,
should consider other factors in evaluating efficacy.
First, there is a distinct possibility that frequency optimisation of the devices concerning bone formation/remodelling has not been established. AcceleDent operates in a low frequency range, however,
research points towards the benefit of high fre-

24 ortho
1 2016

quency in bone modulation. Secondly, current research indicates that high frequency low magnitude
(HFLM) vibration therapy as applied to orthodontic
treatment may have multiple potential benefits,
including, but not limited to, accelerated OTM.
This article will discuss these additional benefits,
including faster more efficient aligner therapy
when used as a nightly seating tool, relief of normal
orthodontic discomfort from new tight fitting aligners and routine adjustments to fixed appliances, and
enhancement of orthodontic retention. Additionally, it will touch upon evidence that HFLM vibration
is useful in increasing bone density and trabecular
bone thickness suggesting applications in implant
dentistry and prosthodontics.

Current vibration devices
used in orthodontic therapy
As mentioned previously, the most common,
commercially available, vibration device for orthodontic treatment is AcceleDent manufactured by
OrthoAccel Technologies. This device delivers a vibrational frequency of 30 Hz and requires 20 minutes
per day user wear time.
Several early studies on the AcceleDent device
seemed to demonstrate higher rates of OTM than
the established norms.8-10 However, there are other
more recent studies that have failed to establish the
advantages of the same therapy. A study by Woodhouse et al. (2015) analysed the AcceleDent device
to demonstrate its effect on OTM in extraction cases.
They found that the supplemental vibrational force
did not significantly increase rates of orthodontic
alignment with a fixed appliance.11 Another comprehensive report on vibration therapy by investigators Yadav et al. (2015) concluded that low frequency mechanical vibration using AcceleDent had
no significant effect in accelerating tooth movement.12
The recent studies regarding the apparent ineffectiveness of AcceleDent may be explained by the

[25] =>

vibration therapy trends & applications

relatively low vibrational frequency of the device.
For purposes of this discussion low and high frequency are defined as:
Low frequency–less than or equal to 45 Hz;
High frequency–greater than or equal to 90 Hz.
In a 2010 study by Judex and Rubin, ovariectomised rats were subjected to either low or high frequency vibration. Bone formation rates for subjects
treated with high frequency were 159 % greater
when compared to controls, whereas bone formation for low frequency rat subjects were not significantly different than controls. Trabecular bone volume and thickness were also significantly higher for
subjects treated with high frequency.13 Similarly
Alikhani et al. found a statistically higher rate of alveolar bone formation (+190 %) at higher frequencies, with a 5 min/day application. In short, the most
pronounced osteogenic effects of vibration seem to
occur well above the AcceleDent’s low vibrational
frequency.14, 18
Practically speaking, five minutes of daily wear
time may be beneficial, as it will reduce the dependency on significant patient compliance. In order to
realise the maximum benefits of vibration therapy,
shorter wear times would logically increase compliance, and improve results. Given all other factors
being equal, the studies suggest that a higher frequency device would deliver equivalent amounts of
HFA Energy to the dentition in a significantly reduced timeframe.

The future of vibration therapy:
Expanded application, multiple benefits
The apparent limitations of current commercially
available vibration devices should not diminish the
potential importance of vibration therapy. Setting
aside applications such as implant dentistry and
prosthodontics suggested by the osteogenic properties associated with vibration therapy, there are at
least four important clinically beneficial orthodontic applications that can be anticipated. These potential applications are: 1) as a nightly clear aligner
seating device; 2) analgesia; relief from normal discomfort associated with orthodontic treatment; 3)
accelerated orthodontic tooth movement; 4) and
enhancement of retention to minimise orthodontic
relapse. What follows is a brief examination of each
of the four applications of HFLM vibration as an orthodontic therapy.
Improved aligner seating
The importance of properly seated aligners, to efficient tooth movement in aligner therapy is clearly
understood. Improperly seated aligners can slow

treatment, forcing patients to back track to previous
trays, and create unintended collateral tooth movements, with a consequence being time consuming
and costly refinements. Seating recommendations
range from using ‘chewies’, to biting on hard objects. Some clinicians advise seating only when trays
are new (immediately post change), while others
recommend daily seating. With the current seating
modalities, it is unlikely that patients consistently
seat aligners fully. A seating protocol, that takes only
five minutes nightly, delivering a range of other patient benefits, would insure that aligners are fully
seated throughout treatment. Consistent proper
aligner seating, would likely result in more efficient,
faster aligner treatment, even absent biomechanical acceleration caused by vibration itself.
Impact on Bone Volume:
High vs Low Frequency Vibration
25 %

20 %

15 %

10 %

High Freq

Low Freq

Non-pharmacological analgesia
Discomfort or pain is a common side effect of
orthodontic treatment. The forces applied to the
dentoalveolar complex which are required to
move teeth, compress the periodontal ligament
(PDL) causing inflammation. Pain is most notable
when seating a new aligner, or immediately after
wire changes and adjustments, when pressure on
the PDL is at its greatest, and diminishes as the
aligner material expands, and/or the dentition
comply. In a study accepted in September 2015 by
the Angle Orthodontist for future publication, Lobre et al found in a randomised clinical trial that
vibration therapy ‘resulted in significantly lower
perceived pain and less OTC medication use.’15 One
theory is that vibration restores normal circulation to the PDL, which is otherwise restricted by
compressive forces. Increased blood flow intercepts the ischaemic response and limits inflammation.

Controls

Graphic 1: Relative impact of
frequency on bone morphology
Increases in bone volume
for high frequency subjects was
25 % higher than controls;
low frequency subjects were not
statistically different than controls.

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| trends & applications vibration therapy
Accelerated OTM
It is well established that bone undergoes formation and resorption in response to external loading
such as gravitational forces, as well as to internal
loading such as muscular activity.16 Recent research
with both animal and human models have demonstrated anabolic responses such as bone growth and
changes in bone mineral density in response to vibration.6, 7, 17 Since OTM is fundamentally based on
bone remodelling (formation and resorption) there
is little doubt that HFLM vibration has the potential
to favourably impact OTM.

% Increase in Alveolar Bone Volume
20 %

15 %

teeth are under force (i.e. from fixed appliances and
aligners). In the absence of force, vibration causes
new bone apposition only, which has potential implications for the retention phase (see below). Note
that the frequency of the device creating the accelerated tooth movement in the Leethanakul study
was in that high frequency range shown to have superior effects on alveolar bone formation by Judex
and Rubin, and Alikani et al.13, 14
Enhanced retention
Vibration therapy warrants the attention of the
scientific community to further explore its effect
during the orthodontic retention phase. Scientific
literature documents that the primary reason for orthodontic relapse is the inability of collagen fibres
(Transseptal fibres and PDL) to reorganise quickly
after the completion of orthodontic treatment and
the delay in new bone apposition.19 Studies suggest
that vibration can have potentially favourable impacts on both bone formation and reorganisation
of the PDL fibres.
A study from Rubin et al (referred above) states
that vibration therapy by itself has always been anabolic, which means it led to bone apposition and
a decrease in bone resorption. Reports have documented an increase in bone density, bone formation,
Type-1 collagen and non-collagenous matrix protein expression in response to the therapy.14

10 %

5%

0%

Low Freq

Graphic 2: Higher Frequencies
are more anabolic
Alikani et al found high frequency
vibration to be most efficient at
accelerating bone growth.
* Statistically different from controls
and low frequency subjects

High Freq*

In a recent split-mouth randomised trial involving bilateral maxillary canine distraction after
first pre-molar extraction on 15 human subjects,
Leethanakul et al. (2015) investigated the impact
of vibration on accelerated tooth movement, as well
as on cytokine activity related to osteoblast and
osteoclast differentiation (specifically IL-1 levels
in GCF). The patients applied vibration to the experimental canine using a commercially available
electric toothbrush operating at high frequency
(125 Hz). This study found significantly increased
tooth movement (~+61 %) accompanied by a threefold increase in average IL-1 levels.18
It can be hypothesised that vibration, amplifies
the familiar osteoblast–osteoclast cellular response
causing bone formation and resorption, when the

26 ortho
1 2016

Recent studies by Yadav et al. (2015) and Alikhani
(2012) (both referred above), have demonstrated
that vibration therapy improved not only bone density, but also restored the integrity and thickness
of the collagen fibres. With evidence suggesting
that vibration therapy positively impacts both bone
morphology and the PDL fibres, vibration during the
retention phase may play a significant role in preventing orthodontic relapse.

Conclusions
1. The current debate over vibration therapy and its
impact on accelerated orthodontic tooth movement, should consider other potential benefits of
this therapy including applications for aligner
seating, relief of normal orthodontic pain, enhanced retention and applications to implant
dentistry and prosthodontics.
2. It can be hypothesised that a vibration device operating in the high frequency range would likely
be most effective in creating OTM as well as offering shorter wear times impacting compliance.
The most commonly available commercial device
operates at a frequency that is below thresholds
having statistical significance in creating orthodontic tooth movement as documented in several

[27] =>

vibration therapy trends & applications

recent studies, and requires a relatively long,
20 minutes daily wear time.
3. The strong supporting data concerning the positive effects of vibration therapy on bone formation, bone density and collagen fibre reorganisation leads us to believe that this modality of
treatment may revolutionise the concept of orthodontic retention.
4. The effects of high frequency vibration therapy
may be useful in modifying the bone density to
the clinician’s advantage in implant placement or
to maintain the thickness of bone trabeculae in
edentulous patients undergoing prosthodontic
treatment._

References
[1] T.J. Fischer. Orthodontic treatment acceleration with corticotomy-
assisted exposure of palatally impacted canines. Angle Orthod.
2007;77:417–420.
[2] M. Cassetta, S. Di Carlo, M. Giansanti, V. Pompa, G. Pompa,
E. Barbato. The impact of osteotomy technique for corticotomyassisted orthodontic treatment (CAOT) on oral health-related
quality of life. Eur Rev Med Pharmacol Sci. 2012;16:1735–
1740.
[3] Alikhani M, Raptis M, Zoldan B, Sangsuwon C, Lee YB, Alyami
B, Corpodian C, Barrera LM, Alansari S, Khoo E, Teixeira C. Effect of micro-osteoperforations on the rate of tooth movement.
Am J Orthod Dentofacial Orthop. 2013;144(5):639–648.
[4] C. Rubin, A.S. Turner, R. Müller, E. Mittra, K. McLeod, W. Lin, et al.
Quantity and quality of trabecular bone in the femur are enhanced
by a strongly anabolic, noninvasive mechanical intervention.
J Bone Miner Res. 2002;17(2):349–357.
[5] R. Garman, G. Gaudette, L. Donahue, C. Rubin, S. Judex. Low-
level accelerations applied in the absence of weight bearing
can enhance trabecular bone formation. J Orthop Res. 2007;
25(6):732–740.
[6] C. Rubin, R. Recker, D. Cullen, J. Ryaby, J. McCabe, K. McLeod. Prevention of postmenopausal bone loss by a low-magnitude, high-frequency mechanical stimuli: a clinical trial assessing compliance, efficacy, and safety. J Bone Miner Res.
2004;19(3):343–351.
[7] M.P. Verschueren, M. Roelants, C. Delecluse, S. Swinnen, D.
Vanderschueren, S. Boonen. Effect of 6-month whole body vibration training on hip density, muscle strength, and postural control
in postmenopausal women: a randomized controlled pilot study.
J Bone Miner Res. 2004;19(3):352–359.
[8] Kau, Chung H., Jennifer T. Nguyen , and Jeryl D. English. “The
clinical evaluation of a novel cyclical force generating device in
orthodontics.” Orthodontic Practice. 2010; 1:1.
[9] Bowman, S. Jay. “The Effect of Vibration on the Rate of Leveling
and Alignment.” Journal of Clinical Orthodontics. 2014;48(11):
678–688.
[10] Dubravko Pavlin DMD, MSD, Ph.D., Ravikumar Anthony MSD,
Vishnu Raj DDS, MS, Peter T. Gakunga DDS, Ph.D., Cyclic Loading
(Vibration) Accelerates Tooth Movement in Orthodontic Patients:
A Double-Blind, Randomized Controlled Trial. Semin Orthod.
http://dx.doi.org/10.1053/j.sodo.2015.06.005.

|

[11] N R Woodhouse et al. Supplemental Vibrational Force During
Orthodontic Treatment: A Randomized Study, Journal of Dental
Research. May 2015; 94(5):682–689.
[12] Sumit Yadav, Thomas Dobieb, Amir Assefniac, Himank Guptac, Zana Kalajzicd, Ravindra Nandae. Effect of low-frequency
mechanical vibration on orthodontic tooth movement. AJODO.
September 2015;148:440–449.
[13] S. Judex and C.T Rubin. Is Bone formation induced by highfrequency mechanical signals modulated by muscle activity?
J Musculosketal Neuronal Interactions. 2010; 10(1):3–11.
[14] Alikhani M, Khoo E, Alyami B, Raptis M, Salqueiro JM, et al. Osteogenic effect of high-frequency acceleration on alveolar bone.
J Dent Res. 2012; 91:413–419.
[15] Wendy D. Lobre, Brent J. Callegari, Gary Gardner, Curtis M.
Marsh, Anneke C. Bush, and William J. Dunn. Pain control in
orthodontics using a micropulse vibration device: A randomized
clinical trial. The Angle Orthodontist In-Press. October 2015.
[16] A. Leblanc, V. Schneider, H. Evans, D. Engelbretson, J. Krebs.
Bone mineral loss and recovery after 17 weeks of bed rest. J
Bone Miner Res. 1990; 5(8):843–850.
[17] A Mavropoulosa, S Kiliaridisa, A Bresinb, P Ammann. Effect
of different masticatory functional and mechanical demands
on the structural adaptation of the mandibular alveolar bone in
young growing rats. Bone. July 2004; 35:191–197.
[18] Chidchanok Leethanakula, Sumit Suamphanb, Suwanna Jitpukdeebodintrac, Udom Thongudompornd, and Chairat Charoemratrotea. Vibratory stimulation increases interleukin-1 beta
secretion during orthodontic tooth movement. The Angle Orthodontist. September 2015; 85(5):899–899.
[19] Birgit Thilander. Biological basis of orthodontic relapse. Seminars in orthodontics. 2000; 6:195–205.

about
Dr Amit Lala, DDS, PhD,
earned his Master’s Degree in
Oral Biology from the University
of California in Los Angeles.
He then earned his DDS and
PhD in Oral Biology from SUNY
Buffalo, NY. He also completed
his postgraduate residency in
Orthodontics at SUNY, Buffalo,
NY. Dr Lala is affiliated with Harvard School of Dental
Medicine as a lecturer in the fields of Orthodontics and
Oral Biology.

ortho
27
1
2016

[28] =>

| trends & applications tooth extractions

© Komsan Loonprom /Shutterstock

Avoiding common problems
in tooth extractions
Author: Dr Kamis Gaballah, UAE

The last two decades have seen significant advances
in restorative techniques and materials for dentistry.
The latter, along with community-based preventive
measures that aim to reduce the incidence of caries,
have resulted in many patients living with functional
teeth for a longer period. Yet, extraction of teeth
forms the considerable bulk of the workload in oral
surgeries o wing to several factors, including the late
presentation of patients with advanced dental disease, the presence of symptomatic impacted teeth,
such as third molars, and the need to extract teeth for
orthodontic or orthognathic treatment.
The extraction of teeth varies greatly based on the
type of patient who is undergoing the procedure. For
example, elderly patients with significant co-morbidities and on a complex combination of medications as
compared with young healthy individuals render the
procedure complicated and require much more preparation with modifications during and after patient
management. Additionally, extractions can range from
a single, fully erupted tooth with favourable morphology to multiple misaligned, impacted teeth or teeth
with challenging morphology. Local anatomy, such as
tooth proximity to the nerve, maxillary sinus and tu
berosity, also plays a significant role. These variations

28 ortho
1 2016

usually dictate who is to perform the extraction, as
many general practitioners deal with less complicated
cases of dental extraction in individuals regarded as
healthy patients and may not feel comfortable operating on medically complex patients.
Complex extraction cases have been linked to a
higher rate of postoperative complications; therefore,
a cautious and systematic approach should be adopted that includes a detailed preoperative a ssessment
to predict the potential difficulties that might arise
during extraction. The documentation of all complicating risk factors along with their potential postoperative morbidities is crucial and should be included in
the informed consent. In the following article, other
useful tips will be provided that are not usually included in traditional textbooks or lecture notes to help
general practitioners to perform safer extractions.
During clinical examination, it has been proven
useful to observe the patient’s build. Tall and muscular
individuals tend to have a long ramus with a higher
mandibular foramen, and this increases the possibility of failure of the inferior dental nerve block procedure if the former is not taken into account when determining the height of the injection site. This can be

[29] =>

tooth extractions trends & applications

aided by tracing the inferior dental canal (IDC) to the
mandibular foramen in the preoperative panoramic
radiograph. The teeth of such individuals may also
have longer and more curved roots and be embedded
in highly dense, compact alveolar bone, and thus sectioning of the teeth may be required to ease the resistance. Racial differences should also be taken into account, as extractions of teeth from individuals of
Afro-Caribbean descent tend to be more challenging
owing to the hardness of their bone and divergence
of roots in their molars.
The resistance of hard tissue should be expected,
particularly if maxillary second and third molars are being extracted, as the potential for fracture of both the
buccal plate and the tuberosity is relatively common
when excessive force is applied with dental forceps.
Fracture of the tuberosity may produce irregular sharp
bony boundaries, significant soft-tissue laceration and
potentially an oroantral fistula. If such risk factors are
identified, tooth sectioning should be followed by elevation of roots with dental luxatomes instead of traditional elevators or forceps, which are known to deliver
much higher force to the alveolar bone.
The indications for the extraction of impacted
lower third molars (LM3) have been the subject of
long-standing debate. Surgical procedures for the extraction of unerupted LM3 are associated with significant morbidity. This includes pain, swelling and the
possibility of temporary or permanent nerve damage,
resulting in altered sensation of the lip, chin, gingiva
or tongue. Damage to the inferior dental nerve (IDN)
is a well-known complication of surgical extraction of
deeply impacted LM3. It should be acknowledged that
this is not simply a loss of sensation; the damaged
nerve can be responsible for a number of abnormal
sensations, including sharp pain and abnormal response to stimuli, such as the perception of a light
touch as a sharp stab. This can have a significant impact on quality of life for many patients.
Injury to the IDN may occur from compression of the
nerve, either indirectly by forces transmitted by the
root and surrounding bone during elevation or directly
by surgical instruments, such as elevators. The nerve
may also become transected by rotary instruments or
during extraction of a tooth whose roots are notched
or perforated by the IDN. The risk factors for IDN injury
during extraction of LM3 are shown in Table I.
Preoperative radiographic investigations may include intra-oral images, such as occlusal radiographs;
panoramic views of the jaws; and conventional CT or
CBCT scans. It should be noted that risk-predicting
signs in radiographs only indicate that there is an increased risk of nerve damage associated with the extraction of the corresponding third molar. However,

Risk factors for IDN injury during LM3 extraction
Overall risk factors for IDN injury

Radiographic signs of increased risk
of IDN injury

Full bony impactions

Apices of the LM3 located inferior to the
lower border of the IDC

Horizontal impactions

Darkening of the root

Use of burs for extraction

Abrupt narrowing of the root

Radiographic risk markers

Interruption and loss of the white line
representing the IDC

Clinical observation of the bundle during
surgery

Displacement of the IDC by the roots

Excessive bleeding into the socket during
surgery

Abrupt narrowing of one or both of the
white lines

Patient´s age

Representing the IDC most of dentists and
surgeons

they cannot actually prevent the nerve injury if the
tooth is to be extracted. The effective strategies that
may avoid or minimise the risk of injury to the IDN can
be collectively categorised into two main sets. The
first is the preoperative workup, which should include
critical assessment of the need to extract the third
molar, clinical examination and radiographic investigation, and the second is intra-operative measures,
including proper selection of local anaesthetic agent,
the injection technique, modification of the surgical
procedure and measures to reduce the degree of potential injury to the nerve.
Most literature published in the last decade has
given us sufficient evidence to suggest a significant
risk of damage to both the inferior dental and the lingual nerve owing to the nerve block procedure.
This injury may be related to the pharmacological
properties of the agent itself or the injection technique. Studies have shown that the lingual nerve is
affected approximately twice as often as the IDN, and
one reason for this may be the fascicular pattern in
the region where the injection is given. It also appears
that about half of patients feel an electric shock sensation during injection.
There is a higher incidence of reports of nerve injury after the use of articaine and prilocaine. Although the reason for this remains unknown, it has
been suggested that this may be because they are 4 %
solutions, whereas the other commonly used local
anaesthetics have lower concentrations. Others associate the damage with the neurotoxicity potential of
4 % articaine and 3–4 % prilocaine. Hence, it is rec-

ortho
29
1
2016

[30] =>

| trends & applications tooth extractions
ommended that the use of such anaesthetics be limited to local infiltration. It has been claimed that needle contact with a nerve felt by the patient as an
electric shock is r elated to injection injury. An obvious
explanation is that the possibility of mechanical injury to the nerve is more likely in the case of multiple
repeated attempts at the inferior dental nerve block
procedure. Therefore, it is crucial that the operator
achieve optimal pain control with minimal episodes
of injection with minimal doses of anaesthetic agent.
The surgery should be planned according to the information obtained from the preoperative assessment process. The procedure itself should aim to minimise the manipulation around the IDC. Both should
include the carefully planned access, tooth sectioning
and elevation techniques. In many scenarios, the extraction of the whole tooth may carry an unavoidable
risk of injury to the nerve, therefore intentional retention of parts of the tooth was proposed via a planned
procedure introduced around 20 years ago called coronectomy. This is the removal of the crown of a tooth,
leaving the root in situ. It is merely adopted to avoid
or minimise damage to the IDN. The rate of complications after coronectomy is comparable to that
observed after surgical extraction, except with a significantly low incidence of injury to the IDN.
It should be noted that both sectioning and coronectomy can be performed with a shorter incision, as
the amount of bone removal required is minimal, thus
minimising the postoperative morbidity. However, it
cannot be performed in all cases in which the LM3 is
close to the IDC and is certainly contra-indicated
when the LM3 is decayed or its roots are associated
with a pathology and should be considered with caution in severely inclined mesio-angular and horizontal impaction cases. The author does not recommend
distal bone removal or retraction of the lingual flap
with the intention of protecting the lingual nerve, as
these may increase the risk of damaging the lingual
nerve. It should be emphasised that incision may not
extend beyond the distobuccal aspect of the tooth.

contact

Dr Kamis Gaballah
Educated in the UK and Ireland,
Dr Kamis Gaballah is currently
an associate professor and
senior specialist in oral and
maxillofacial surgery at the
Ajman University of Science and
Technology in the United Arab
Emirates. He can be contacted
at kamisomfs@yahoo.co.uk.

30 ortho
1 2016

The other important aspect of the dental extraction
procedure is the future replacement of the tooth to be
extracted. The current trend of tooth replacement for
both functional and aesthetic reasons is the placement of dental implants. The success of this treatment largely depends on the availability of healthy
bone in sufficient volume. Therefore, it is crucial for
the dental practitioner not to compromise the alveolar bone during extraction of the teeth. Changes in the
alveolar bone ridge after an extraction are inevitable.
After all dental extractions, bone height and width always undergo dimensional changes. Bone does not
regenerate above the level of the a lveolar crest, that
is, its height will not increase during healing. The buc-

cal plate tends to shrink, shifting the crest of the alveolar ridge lingually, and often forms a concavity. Such
changes are proportional to the amount of trauma to
the soft- and hard-tissue during the extraction.
An additional unfavourable change that may take
place is the slow remodelling of the bone formed to fill
up the extraction socket owing to lack of functional
stimulation. The presence of poorly remodelled alveolar bone may compromise the stability and function of
the future implant. Furthermore, studies show that the
stripping and elevation of mucoperiosteal tissue produce a higher number of osteoclasts within the alveolar ridge and hence greater resorption and shrinkage
are seen after the classical surgical or the traumatic
extraction of teeth.
The preservation of alveolar bone for future implant
placement may be achieved by avoiding unnecessary
bone removal and stripping of the periosteum during
surgery, as well as performing a surgical alveolar bone
preservation procedure. Bone removal can be largely
avoided or minimised through modification of the tra
ditional extraction technique.
The first such modification is the use of dental periotomes and luxatomes to gently strip the periodontal
ligament fibres and widen the socket without causing
cracks or fracture of the cortical plates, as commonly
encountered when using dental forceps or the bulky
elevators. The use of such gentle instruments also
eliminates the need for elevation of mucoperiosteal
tissue. However, it should be noted that the safe use
of these instruments requires adequate training and
should be encouraged during undergraduate clinics.
Clot stabilisation through light packing of the socket
with collagen sponges may help to minimise clot dislodgment, as well as accelerate the healing process
and bone regeneration.
The second strategy is the alveolar bone preservation procedure. This includes packing the extraction
socket with different fillers, such as osteoinductive or
osteoconductive materials, like autogenous, natural
or synthetic bone grafting materials that support the
alveolar socket walls, thus preventing their collapse
and shrinkage. It should be noted that this intervention
can only slow down the post-extraction changes to
improve the success of the dental implant, but cannot
stop them a ltogether.
Finally, post-extraction care should include an
explanation of the healing process and potential
symptoms encountered a fter such procedures. The
prescription of medications should be limited to non-
steroidal anti-inflammatory drugs in most cases and
imprudent use of antibiotics or socket dressing should
be avoided._

[31] =>

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eCligner utilizes a 3D digital program based on traditional orthodontic principles to achieve true
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Treatment Kits come with the resin models for each step. Lost or broken aligners can be replaced by
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The ecligner selfie service is an innovative mobile application that helps you monitor patient
progress between appointments.

[32] =>

| industry report palatal expansion screw

Trial of a new rapid
palatal expansion screw
Authors: Drs Gabriele Galassini, Elena Marcuzzi & Paulina Natasa, Italy

Introduction
Rapid palatal expansion has been a well-established
procedure in orthodontic practice for many years now.
The first expansion was performed in 1860 by Emerson C. Angell, who, in San Francisco, expanded the
maxillary arch of a fourteen-and-a-half-year-old girl
by a quarter of an inch in 2 weeks and noted the creation of an interincisal diastema, a sign that the expansion of the palatal suture had occurred. This expansion was published in Dental Cosmos San
Francisco Medical Press in 1860.
Different types of screws and activation protocols
have been developed over the years.

External examination of the screw
(Figs. 1a & b)
·· Compact in appearance (7.5 x 12 mm) with rounded
edges and a very smooth structure.
·· The small screw cylinder has four teeth for preventing return.
·· Small casing to prevent the screw from unwinding.
·· Notches for controlling the amount of activation:
each notch corresponds to 2 mm of activation.
·· Stopping pins which firmly block the (Expander)
once opened.
This device prevents complete separation of the
screw, with its subsequent disconnection and accidental opening of the two parts of the Expander.

Bench testing (Figs. 2a & b)

In the following project, we tested an innovative
screw, the characteristics of which allow for safe and
effective activation, the quantity of which can be easily controlled.

The opening of the screw with the special key was
tested. The direction of activation is clearly indicated

Fig. 1a

Fig. 1b

Fig. 2a

Fig. 2b

Figs. 1a & b: External examination
of the screw.
Fig. 2a: Screw activated at 4 mm.
Fig. 2b: Screw activated at 8 mm –
note the stopping device.

32 ortho
1 2016

[33] =>

palatal expansion screw industry report

Fig. 3c

Fig. 3d

Fig. 3a

with a very visible arrow printed on the body of the
Expander.
The screw is activated by turning the key as far
as it will go. At the end of each activation a loud
click sound is heard, which is made when it meets
the braking ring, provided with the device. The
braking ring prevents the screw from unwinding
when the activation screw is removed. This ensures the screw has been activated correctly and
allows for the simple reinsertion of the key at the
next activation, leaving the insertion hole perfectly accessible.
There are notches for controlling how much the
Expander is activated.
The first two notches are stamped onto the body
of the Expander, while the others are stamped on
the concentric sliding guides. The latter notches
are therefore visible during activation while the
screw is opening.

Fig. 3e

Fig. 3b

Clinical test (Figs. 3a–e)

Figs. 3a–e: Five-year-old patient with
left-sided cross bite.

We tested the Expander on a 5-year-old patient with
a left-sided cross bite. We wanted to choose a very
young patient with a very small palate, given that it is
mainly in these patients that difficulties are most frequently encountered when activating the screws. These
difficulties are linked to the confined spaces available
for operating in. As a result, when the parent removes
the key after activating the screw, he/she almost always
tends to bring the screw back again, reducing how much
they have activated it by. As a result, it is difficult for the
clinician to evaluate the real amount of expansion.
Activation protocol
The Expander was bonded to two bands and cemented onto the second deciduous molars and the rapid
expansion protocol was implemented, which provides
for the activation of the screw twice a day (Figs. 4a & b).
We asked the parents to do this themselves, but remained contactable at all times for anything they
needed or in case of emergency.

Figs. 4a & b: The Expander was
bonded to two bands and cemented
onto the second deciduous molars.
Figs. 5a & b: On the 14th day we
terminated activation as the
pre-determined expansion level of
5.5 mm had been reached.

The notches are positioned 2 mm apart from
each other.
Each activation moves the screw forward by
0.2 mm, corresponding to a 1/4 turn of the total
circumference of the screw.
The screw is therefore particularly stable for the
whole expansion process; this is thanks to the
double concentric sliding guide, which is one of
the peculiarities of this Expander.
The Expander remains stable until its maximum
opening limit is reached, at which point it blocks
without disconnecting the screw itself, thanks to
a solid stopping device. This means it is possible to
take advantage of the full length of the screw in
absolute safety.

Fig. 4a

Fig. 4b

Fig. 5a

Fig. 5b

ortho
33
1
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[34] =>

| industry report palatal expansion screw
ing advantages: it reduces the encumbrance to the
palate. In fact, often owing to its encumbrance, the
rapid Expander forces the tongue into a low, forward
position, with a subsequent open bite from lingual
dysfunction.
As well as maintaining the breadth obtained with
the rapid expander, the Quad helix can also increase
it, by activating it by the required amount.

Fig. 6
Fig. 6: The Expander remained
blocked in the mouth for 1 month and
was then replaced with a Quad helix.

The patient was examined after one week. The
parents reported that they had noted the creation
of an inter-incisive diastema on the 5th day, as is
generally the case at this age, from our experience.
We discharged the patient after having personally
activated the screw to check its stability and the efficacy of the stopping device.

contact

On the 14th day, we terminated activation as the
pre-determined amount of expansion of 5.5 mm
had been reached (Figs. 5a & b). The correct amount
of activation was confirmed by the reference
notches. As you can see from the photo, the third
notch is about to appear, indicating 6 mm, but is still
slightly hidden by the sliding guide, while the two
previous notches are clearly visible on the body of
the Expander.

Dr Gabriele Galassini
is a surgeon and orthodontist.
Dr Galassini has been a contract
Professor at Scuola di Specialità
in Ortognatodonzia, Univesity of
Trieste since 2005. He is also a
lecturer at Osteopathic College
in Trieste.
Via Crociera 10
34074 Monfalcone (Go)
Italy
segreteria@studiogalassini.it
www.studiogalassini.it

The Expander remained blocked in the mouth for
1 month and was then replaced with a Quad helix
(Fig. 6), which includes a marker for lingual repositioning.
The Quad helix remained in the mouth for another
4 months, after which no other type of restraint was
required. This protocol provides for the replacement
of the rapid expander with a Quad helix 1 month
after the end of activation. It is a protocol we have
been using for more than 20 years and has been
tested on more than a hundred cases, proving to be
particularly effective and free of any contraindications.

Thanks to the lingual marker, together with the
modest encumbrance to the palate offered by the
Quad helix (note its modelling in the photo), myofunctional re-education can be initiated immediately. This is definitely more important, in terms of
the stability of the expansion and the prolonged use
of the expander as a maintenance guard, given that
the same prevents correct lingual repositioning,
an indispensable condition for the stability of our
treatment in the long term.
In addition, since it is an elastic device, the Quad
helix does not block the two hemimaxillae together,
thus allowing the jaw to adapt to the occlusal
forces, certainly a useful condition for the cranial
architecture, which is also welcomed for osteopathic treatment.

Conclusions
In both bench and clinical testing, the Expander
has proven to be extremely precise, assembled with
care, solid and without any flexion.
The parents of the patient activated the screw at
home with particular ease and precision, thanks to
the braking device. In fact this feature enabled them
to hear a ‘click’ upon each activation, and above all
to not turn the screw back when removing the key,
thus undoing the activation they had just completed. This is such a frequent occurrence during the
activation of traditional Expanders. The whole process went ahead without any problems and with the
maximum level of comfort for the young girl, thanks
also to the compact size of the Expander, permitting
effective and safe use in very young patients.

Dr Elena Marcuzzi
Surgeon, Orthodontist
Specialist

In fact in our opinion, 1 month is more than
enough for the consolidation of the midpalatal suture, given that this is the average time required for
the consolidation of fractures.

The arm and the screw of the Expander were
proven to be precise and without any flexion. The
reference notches printed on the screw enabled the
clinician to check that the activation had been performed correctly. All this resulted in a greater sense
of security for both the patient and the therapist, as
well as being appreciated as an indicator of a high
level of professionalism._

Dr Paulina Natasa
Orthodontist

The replacement of the Expander with a Quad helix provided with a lingual marker offers the follow-

Editorial note: A complete list of references is available from
the publisher.

34 ortho
1 2016

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© Propel Orthodontics 2016

*Alikhani M, Raptis M, Soldan B, et al . Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 144:639-48; 2013.

propelorthodontics.com

opel_DT_2015.indd 1

(855) 377-6735

© Propel Orthodontics 2016

*Alikhani M, Raptis M, Soldan B, et al . Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 144:639-48; 2013.

1/23/15 2:29 PM

[36] =>

| industry report NimrodAligner

From straightforward
to complex cases
The new NimrodAligner and why it can be the
ultimate orthodontic removable aligning system
Authors: Nimrod Tal & Lauren Flannery, UK

Fig. 1

Fig. 2

Figs. 1–5: Designed to move from 5-5
in all directions, and also widen the
molars, the NimrodAligner comprises
of lingual and labial arch wires
attached to individual cups that seat on
each tooth with the aid of a composite
anchor, and a connecting bar to seat
on the palate or the lingual area, that
are attached to molar cups.

As a dental practitioner, helping your patient look
to improve their smile by undergoing orthodontic
treatment with one of the many aligning systems
available can be a very daunting decision to make
when it comes to choosing the right system. Whatever their lifestyle, the attributes most commonly
sought after are typically comfort, discreteness and
for the treatment time to be as speedy as possible.
Depending on the case, it can sometimes be quite
difficult to achieve all of these aims within one single aligning system, as each are designed to achieve
very specific and individual movements, and not all
are designed to do this with the whole arch.
As an orthodontic laboratory, we are introduced
to hundreds of very individual cases on a weekly basis, where more often than not patients will have
specified that the above a ttributes are key to their

36 ortho
1 2016

decision making process when we assess for the appliances that will be best suited to their particular
case. After having been faced so regularly with the
task of assisting our clients to make the decision that
will benefit their patients in as many aspects as they
can, we had a thought—what if the advantages of
each of these aligning systems were combined, and
the disadvantages eliminated? It was from this that
the idea of our brand new NimrodAligner stemmed.
Designed to move from 5-5 in all d irections, and
also widen the molars (Fig. 1), the NimrodAligner
comprises of lingual and labial arch wires attached to individual cups that seat on each tooth
with the aid of a composite anchor, and a connecting bar to seat on the palate or the lingual
area, that are attached to molar cups. After h
aving
spent four years researching the most effective

[37] =>

NimrodAligner industry report

components and combining them using prototypes with 3-D printers, we have combined the
biomechanics of straight wire, Clear Aligners and
a spring aligner to reduce the downsides of having treatment considerably and focus more on the
positive features.
Typically most common with adolescents, fixed
brackets appear to be decreasing in popularity,
mostly due to the fact that they are not particularly
aesthetically pleasing and can therefore encourage a feeling of embarrassment for adults when in
public. Combined with hours of clinical time spent
fitting and repositioning the individual brackets,
hygienic problems owing to not being able to brush
or floss properly, as well as the discomfort of their
often sharp exterior both labially and lingually, it is
no surprise that they are not as often requested
as more popular removable aligners. The Nimrod
Aligner has the fixed brackets arch wires biomechanics incorporated within the removable appliance so clinical time is extremely minimal. The
teeth and gums can also be cleaned to the proper
standard and at only 2 mm in thickness (Fig. 5)—as
opposed to the s tandard 3 to 3.5 mm thickness of
fixed brackets—so the overall feel is very anatomically friendly.
Clear Aligners are the most anatomically friendly
appliances on the market today, and are mostly popular because of just how discreet they are. Despite
these advantages, the force and pressure induced
during the initial days of wear can be very painful.
Although a sign that they are working as they
should, the aligners tend to become passive as time
passes and are typically only at their most active in
just the first seven days. On the other hand with the
NimrodAligner, NiTi wires ensure that the pressure
is gentle, yet provide continuous support.
Multiple Clear Aligner trays can also become very
tedious for both patient and dentist, particularly

Fig. 3

when frequent appointments are necessary and
stages of interproximal reduction (IPR) have to be
carried out. IPR can be a huge factor in the progress
of Clear Aligners as each aligner is made to incorporate the necessary IPR after each stage and the fit of
following trays will be affected if not enough has
been done. This is not a problem for the Nimrod
Aligner as it will not affect the fit of the appliance if
there has been insufficient IPR on the previous appointment. The patient can continue to wear it and
IPR can be completed where necessary on the next
appointment.
Similarly, spring aligners can also continue to be
worn and fit c orrectly in between appointments if
not enough IPR has been done previously, however
they’re widely known for limited movement to just
four incisors. It may be good for labial/lingual movement using the ‘squeeze’ effect, and some rotation,
but Clear Aligners can o ften be required to finish.
In some instances, a separate expansion appliance may be required prior to treatment, which
essentially boosts costs and adds time onto treatment overall. We have reduced this concern by
offering this stage for such cases within the
NimrodAligner singularly.

Fig. 4

Fig. 5

ortho
37
1
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[38] =>

| industry report NimrodAligner

Fig. 6

Fig. 7

Fig. 8

Fig. 9

Figs. 6–9: By combining all of the
positive aspects of different
orthodontic appliances, the
NimrodAligner can be suitable for most
cases from straightforward to complex.

The arch can gain molar width by pre-setting the
molars in a wider position when it comes to making
the movements on our 3-D system, and the connecting bar can act as a spring thanks to its flexibility.

nated the need for this by designing the Nimrod
Aligner in a way that allows the entire arch to move
in any direction. In case expansion is also required,
we have this incorporated (Fig. 1).

The rest of the teeth will continue to be aligned
during this process.

We have adapted the force and pressure of the
movement to be effective for just sixteen hours a day,
allowing the patients to remove the appliance for an
entire eight hour working day if they wish, to grant
the roots a sufficient amount of time to recover.

In more complex cases however whereby a separate expansion appliance is unavoidable, two
NimrodAligners will be provided. The caps will not fit
on the teeth that are blocked in otherwise, so the initial appliance will create space for the blocked teeth.
Once they have been exposed, the second appliance
would be provided to sit on all of the teeth.
During our research and production stages, we
aimed to create the u ltimate orthodontic removable
aligning system that could potentially be the answer
to the prayers of dentists and patients alike. We have
reduced clinical time dramatically by removing the
time-consuming hassle of fitting appliances such as
fixed brackets by providing a bespoke pre-aligned
appliance that simply needs to be placed on the
teeth. We have taken into consideration the fact
that multiple appliances can sometimes be necessary to achieve the desired result, and have elimi-

38 ortho
1 2016

By combining all of the positive aspects of the orthodontic appliances mentioned above, the Nimrod
Aligner can be suitable for most cases from straightforward to complex._

contact

Nimrod Tal is the director of
NimroDENTAL Orthodontic
Solutions in London.
He can be contacted at
contact@nimrodental.co.uk.

[39] =>

[40] =>

| industry report orthodontic brackets design

The power of precision
Author: Claus Schendell, Germany

Fig. 1

Fig. 1: Precise fit of wire that fills the
slot correctly.

Fig. 2: Microscopic x200 readjusted
for publication/non-photoshopped
CNC bracket and MIM
bracket.

Over the past 25 years of manufacturing, I have been
asked many questions regarding design, material and
manufacturing techniques of orthodontic brackets.
Each time you ask me a question, I realise that the design and manufacturing end of orthodontics must
seem like a top secret file kept safely hidden away. That
can leave you, the orthodontist, dazed and confused
by the varying array of brackets on the market. What
makes them different, how do you choose what is best
for you and your practice?

Every year for the past 10 years, I have selected
brackets from around the world and tested them for
accuracy, always in an effort to improve my technique
or simply to see how others were progressing.

The importance of the intimate fit

I was always ready to discover that perhaps new
manufacturing methods were proving promising.
Year after year, measurements of MIM brackets produced consistently unsatisfactory inaccurate results.
The majority of MIM brackets during my yearly measurement study continuously measured larger than
what was reported by the manufacturers. With a
smaller percentage measuring smaller, this proved
later in my research to be a twofold problem.

In orthodontics, placing maximum prescription
arch wires in a preadjusted bracket is designed to produce three-dimensional, tooth-moving forces (Fig. 1).
These forces can only be created as a result of an intimate fit of the wires into the bracket slot, any gap between these components will result in incomplete
transmission of the bracket prescription to the tooth
and its supporting tissues (Fig. 1).

Fig. 2

We are not all the same
This intimate fit has proved difficult to achieve by
many metal injection moulding (MIM) manufacturers. Numerous scientific studies have discovered
and reported inaccuracy of the orthodontic bracket
slot and the negative influence on orthodontic
treatment (Fig. 3).
Fig. 3: Most commonly used archwire
0.019 x 0.025—Slots at .023 or .024
increase your work because of the loss
of torque control.

Fig. 3

40 ortho
1 2016

I tested the following simple characteristics (Fig. 4):
A Is the slot accurate?
B Are the walls of the slot parallel?
C Are the corners 90 degrees?

1. MIM manufacturing processes are notoriously difficult to manage and control, precision and consistency of each run varies considerably.
2. Bracket and tube dimensions of +/- 3 degree tolerance are acceptable benchmarks by many MIM
manufacturers and are considered as sufficiently
adequate (Fig. 2).
These values have been clinically analysed and have
proven to have a profound influence on torque expression, as reported in numerous clinical publications (Fig. 3).
It is not by accident that within the world of engineering, CNC Milling dominates high-tech products,
high-end watches, Formula 1, and aerospace engineering. Every step can be precisely reproduced over

[41] =>

orthodontic brackets design industry report

der’s2 simple explanation regarding the clinical torque
problem, for every 0.001 inch of freedom between the
archwire and the vertical bracket slot, approximately
5 degrees of effective torque is lost (Fig. 3). Think
about when you apply this explanation to brackets
with single digit torque values manufactured with inaccurate slot sizes, they have little, if any, advantage
over a standard edgewise bracket.

Fig. 4: Profile bracket slot representation
of measurement guides.

Physics helps you choose

Fig. 4

and over with the identical velocity, feed and location,
without any varying components, including human
fatigue. This control enables me to produce bracket
slots less than a thousandth of an inch, every run and
every year for the past 25 years.

The principals of physics will never change; if your
slot is inaccurate it will produce inaccurate results.
This foundation of knowledge will help you navigate
your way through the many bracket choices available
in the market.
Accuracy within the slot is just one of the benchmarks met during the manufacturing of orthodontic
brackets, but we cannot underestimate the significant role it plays for you, the orthodontist.

For orthodontists striving for excellence, it is important to understand that different manufacturing
techniques produce different results. Avoid the mindset that all bracket systems are more or less the same.

Physical principles always stay the same
Inaccurate slots and inaccurate geometry will
result in an incomplete transmission of the bracket
prescription—it is simple physics. Movement of teeth
requires application of forces, and periodontal tissue
responds to these forces. Force mechanics are governed by physical principles such as the laws of
Newton and Hooke.
Newton’s Laws1
·· The law of inertia
·· The law of acceleration
·· The law of action and reaction

What does inaccuracy mean to you?
Inaccuracy within the bracket slot is fully experienced when three-dimensional control is required. For
example, during a case when you require incisor inclination correction, additional root torque would need
to be added to overcome the inaccurate slot. Sadly orthodontists have come to accept, and fully expect oversized slots and lack of precision within the bracket system they use. However accepting this lack of precision
as something that can't be controlled is incorrect.
You should know how to solve these unexpected
tooth movements, but you should not have to due to
manufacturing inadequacies. I always liked Alexan-

Fig. 5

Fig. 5: Microscopic x400 picture of
CNC slot—adjusted for publication—
non-photoshopped bracket slot.

My role and goal as an engineer and manufacturer
is to provide you with true and accurate tools, eliminating the guess work and need to always compensate for a lack of precision, and enabling you to
achieve optimal tooth movement and high-quality
predictable results (Fig. 5)._
References
[1] Biomechnics in orthodontics, Ram S. Nanda, BDS, DDS, MS,
PHD – Yahya S. Tosun, DDS, PHD.
[2] Alexander R. The 20 Principles of Alexander Discipline. Chicago, Il:
Quintessence Publishing: 2008.

contact
Dipl. Ing. Claus Schendell
President of Adenta GmbH
Adenta GmbH
Gutenbergstraße 9
82205 Gilching
Germany
info@adenta.com
www.adenta.com

ortho
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[42] =>

| industry report rapid maxillary expansion

Rapid maxillary expansion:
small details make the difference
Author: Gabriele Scommegna, Italy

Fig. 1a

Fig. 1b

Nowadays, rapid maxillary expansion (RME) is a quite
popular orthodontic therapy since maxillary deficiency is probably the most recurrent problem that
can be detected among patients.

Many years after Dr Angell’s futuristic vision, in the
1970s, Dr Haas reintroduced this therapy by means of
an updated design of a rapid palatal expansor, the socalled Haas expansor1 (Fig. 2).

The history of this therapy goes back to 1860 when
Dr Emerson C. Angell wrote, and Dental Cosmos Fig. 2
published, an article where he reported a
case of a 14-year-old girl with a unilateral
cross bite, treated by means of a jackscrew in order to widen the palate. The
complete expansion was achieved in
only two weeks and the patient showed
an interincisor diastema (Figs. 1a & b).

From that time, RME has been investigated several
times by many authors focusing on the indications,
the right timing, the various clinical procedures, initial outcomes and long-term stability, as well as regarding the influence of
different appliance designs.

Dr Angell was a real pioneer in
dentofacial orthopaedics, and faced
great criticism among the dental
community even if, 35 years before the possibility of proving it by
the use of X-ray, his palatal widening therapy was successfully
and clearly proven today; in 1860
he defined the gold standard for
actual maxillary expansion therapy.
An interesting fact to know but true as well as little
sad, Dr Angell became frustrated with his colleagues’
opinions, so he decided to leave the orthodontic discipline, as well as San Francisco, ending his professional carrier as a medical doctor in the US.

Fig. 3a

Today the ‘hygienic RME’, so called due
to the absence of acrylic contacting with
the palatal mucosa that facilitates oral
hygiene, is largely more popular than the
Haas one (Figs. 3a & b).

Leone, as one of the few orthodontic
screw manufactures in the world, has
played an important role in this development since the very beginning: in the
early ‘70s, Leone started the production
of the first RME dedicated screw, fully
made of stainless steel with four integrated
arms (Figs. 4 and 5).
Since then, Leone has continuously improved the
quality of the material, the production technology as
well as widening the expansor range in order to give
the orthodontist the best tools to fit their various

Fig. 4

Fig. 3b
Fig. 5
Fig. 6

42 ortho
1 2016

Fig. 7

[43] =>

www.adenta.com

Affecting
stability
due to remaining
residuals of wax and
polymers in the
finished product

MIM

molded Brackets
the ordinary method

Up to
+/-20%
slot size tolerance
due to the
difficult control of
the shrinking
process

Rough
surfaces
faciliate the
accummulation of plaque
and development of
micro corrosion

creating the
following clinical
DISADVANTAGES.

[

You only have to look closer
to see the differences!

[

HighEnd
stability
custom-cuts made
from pure solid
stainless steel

CNC

milled Brackets
the extraordinary method

Dimensional
tolerances in a
thousandths of an inch
achieve a slot accuracy
smaller than a human
hair with outstanding
bonding strength and
less failure rates

Absolute smooth
satin finish
prevents accumulation
of plaque and
eliminates
micro-corrosion

providing you with
numerous clinical
ADVANTAGES.

[

BrinGinG GermAn enGineerinG
to ortHoDontics

Seeing is
believing.
mADe in GermAnY.

[
Adenta GmbH | Gutenbergstraße 9 | D–82205 Gilching

p. + 49 8105 73436-0 | f. +49 8105 73436-22 | m. info@adenta.com

[44] =>

| industry report rapid maxillary expansion
arms while each of them bears a laser marked identifying lot number that allows for complete traceability.

Fig. 8

Fig. 9

Fig. 10

Knowing that a RME appliance ‘produces the
greatest dental and skeletal transverse changes by
widening of the upper jaw, by separating the midpalatal suture with large forces over a short time
period, which subsequently allows the creation of
more space for the permanent teeth’ (from Dentalpedia, McGil University, Faculty of Dentistry), we
have always been positively concerned about the
functionality of each screw, thus we have paid maximum attention in all steps from design to the final
quality test.
We have conducted extensive tests in order to know
the mechanic limit of each RME models: our findings
show that the ‘weaker’ component is always the activation key (at over 12 kg of force) that acts as a ‘safety
instrument’. In other words, it is highly unlikely that
the RME will not produce a suture opening in youth
patients, neither will the expansion mechanism be
damaged by the counter force produced by the maxilla (Fig. 6).

Fig. 11

Each part of the RME expansor is produced with
tight tolerances and high polished surfaces to obtain
controlled and precision expansion, once they are
assembled together (Figs. 7 & 8).

Fig. 12

clinical needs. Today, Leone offers a wide range of RME
dedicated screws, all of them designed and manufactured in our high tech production facilities, fully made
by surgical grade stainless steel, with laser welded

Fig. 13

Fig. 16

Fig. 18

44 ortho
1 2016

Leone RME expansor’s unique feature is the connection of the arm to the screw body: the arm fits
perfectly in a blind hole created inside of the housing, then it is held in position by means of external
high power laser welding (Figs. 9–10). This exclusive

Fig. 14

Fig. 15

Fig. 17

[45] =>

rapid maxillary expansion industry report

Fig. 19a

Fig. 20

Fig. 19b

Fig. 21

Fig. 24

Fig. 25

Fig. 19c

Fig. 19d

Fig. 22

Fig. 23

Fig. 26

Fig. 27a

Fig. 27b

method eliminates the possibility of arm detachment both during lab arm bending and in clinical use,
as well as avoiding the overheating of the joint area,
keeping the full strength of the wire thus assuring
the required power.
The orthodontist and the technician can choose
among various models of Leone expansors and appliance designs in order to fabricate the most appropiate
device for the patient (Fig. 11).
Since the RME is an appliance that produces an orthopaedic maxillary modification, the ortodontic lab
technician has to pay attention to the position of the
screw as well of the arms: there are specific rules to be
followed, as shown in Fig. 12.
We have designed specific tools to facilitate the lab
procedures, avoiding the unwanted damage of the
screw mechanism, as well as the overstress of the
arms (Figs. 13–15).

Fig. 28

A smaller expansor (Fig. 18) with two arms was
developed for use in younger patients with mixed
dentition and reduced palatal volume.
Figures 19a–d (courtesy of Dr A. Fortini, Florence, Italy) gives an example of the use of the smaller expansor.
A RME with orthogonal arms has been developed
in order to reduce the overall bulkiness, keeping a
maximum stability thanks to the doubled guided pins
expansion mechanism (Figs. 20–23; Figs. 22 & 23
courtesy of Prof. Franchi, University of Florence, Italy).
A special fan type RME has been developed to enhance the anterior space gaining in cases with intercanine diameter (Figs. 24–26; Fig. 26 courtesy of
Dr E. Schellino, Turin, Italy).

Leone RME screw range with four arms have an
expansion capacity ranging from 7 mm to 13 mm
(Fig. 16).

Maxillary expansion can also be obtained by means
of a spring-loaded screw such as the newly developed
Leaf expander that can produce two force levels,
900 g and 450 g, giving the orthodontist the possibility to expand the maxilla dentally and/or basally
(Figs. 27 & 28; Figs. 27a & b courtesy of Dr C. Lanteri,
Casale Monferrato, Italy).

Figure 17 (courtesy of Prof. P. Cozza University of Tor
Vergata, Rome, Italy) shows a RME Butterfly design.

Thank you Dr Angell for your intuition that has literally 'expanded' the orthodontic possibilities!_

Reference
[1] Haas AJ: The treatment of maxillary
deficiency by opening the midpalatal suture. Angle Orthod 35:200217, 1965.

contact
Gabriele Scommegna
Research and Develpment
Director of Leone S.p.A.
Leone S.p.A.
Via P. a Quaracchi, 50
50019 Sesto Fiorentino
Florence, Italy
info@leone.it
www.leone.it

ortho
45
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2016

[46] =>

| industry report Light Accelerated Orthodontics

Shortening treatment time
by using OrthoPulse
By Biolux Research Ltd.

OrthoPulse uses safe, low intensity near infra-red
light (850 nm wavelength) to facilitate bone remodelling on a molecular level without any adverse effects.
This is the only device of its kind cleared by the US FDA
for use with both fixed appliances or clear aligners.

Case presentation
Patient diagnosis
A 24-year-old female presented with Class I occlusion, a deep bite, and crowding along with a narrow
maxillary and mandibular arch form (Fig. 1). Her right
muscles of mastication, including the lateral pterygoid, were tender upon palpation. Incisors were
asymmetrical due to bruxism.

Fig. 1
Fig. 1: A panoramic X-ray of the initial
situation.

Fig. 2: A cephalometric X-ray of the
initial situation.
Fig. 3: Initial situation.

Fig. 2

Introduction
OrthoPulse is a clinically proven device that uses
low levels of light energy to stimulate the periodontium and alveolar bone surrounding the roots of the
teeth and facilitate tooth movement which may reduce treatment time.

Fig. 3

46 ortho
1 2016

Treatment goal
The patient was prescribed with Invisalign treatment to align teeth, broaden both arch forms to fill
buccal corridors and improve upper cuspid torque.
Aesthetic enameloplasty was also proposed to conceal bruxism wear.

[47] =>

Light Accelerated Orthodontics industry report

Fig. 4

Adjunctive OrthoPulse treatment of 5 minutes
per arch daily was implemented to accelerate
aligner progression, which occurred based on
self-assessment. In a daily questionnaire, the
patient was asked to report the following:
1. pain, a common side effect of orthodontic treatment due to applied forces,
2. air gaps, to monitor fit between orthodontic appointments and
3. pressure, as an indicator of orthodontic force magnitude.

achieved in a time period of less than four months.
The patient was changing Invisalign aligners every
5.5 days during her OrthoPulse active study phase.
An interesting finding was that she was able to
change aligners during her refinement/fine-tuning
phase at the rate of every 4 days using OrthoPulse.
Overall treatment time was less than one year, but it
is important to note that several of the 12 months
included non-OrthoPulse periods during the study
and waiting for additional aligners during the refinement phase._

When pressure was given the lowest rating, the
patient would switch to her next aligner. The orthodontist, as expected, was in charge of the entire
course of the treatment and verified tracking of the
teeth in aligners during regular appointments.

Clinical case prepared by Dr Todd Dickerson, USA.

Analysis of results achieved
Treatment using OrthoPulse progressed well.
Archform development and tooth alignment were

Fig. 4: Final result on a panoramic
X-ray.

contact
Biolux Research Ltd.
220–825 Powell St.
Vancouver, BC, V6A 1H7
Canada
www.orthopulse.com

Fig. 5: Final cephalometric X-ray.
Fig. 6: Final result.

Fig. 5

Fig. 6

ortho
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[48] =>

| feature interview

“We will be able to treat
pretty much everything
in the future”
future
An interview with Dr Graham Gardner, UK, President of the European Aligner Society

The European Aligner Society is an international
organisation established in 2013 that aims to promote education and research in aligner therapy.
Trained in South Africa and with 22 years of clinical
experience, Dr Graham Gardner has been running
his own private practices in the UK since 2008.
In an interview with Dental Tribune International,
the EAS President shares his ideas and views about
the importance of aligners in orthodontics and
about the EAS, which he believes will become the
society for aligner therapy.

Dr Graham Gardner

DTI: Dr Gardner, you have been working with
aligners for more than a decade now. What
convinced you initially of this treatment method
and what are the main advantages in your
experience?
Dr Graham Gardner: From the beginning of my
career in the early 1990s, a time when ceramic
brackets and lingual braces became available, I was
certainly aware of the fact that aesthetic appliances
were going to be the future of orthodontics.
In 2001, I was fortunate to attend a certification
course for Invisalign, which was truly a watershed
moment in my orthodontic career because I saw
the value and potential of aligner therapy for both
dental professionals and patients. In my opinion,
aligner therapy opened the door for a huge cohort of
patients who would not have considered orthodontic
therapy in the past mainly owing to aesthetic concerns. In addition to aesthetic benefits, aligners are far
more comfortable than fixed appliances, as they are
removable and hence facilitate oral hygiene during
therapy.
They also move the teeth more gently with less
pressure, which is favourable with regard to patient
comfort and from a biological perspective too.

48 ortho
1 2016

Today, I treat over 75 per cent of patients with
Invisalign in my practices.
In recent years, clear aligners have become a
favourable treatment alternative to fixed appliances, and the global orthodontic supplies
market is expected to reach about US$3.9 billion
(€3.6 billion) by 2020. In your professional
opinion, how will this market develop in the near
future?
Over the past decade, aligners have become
mainstream orthodontics and I definitely see this
trend continuing and expanding.
With the technological advancements, including
3-D and CAD/CAM, that allow the clinician to diag-

[49] =>

feature interview

|

“...the advancements we are now
seeing in Europe will match those in
America and Asia...”

Vienna © mRGB / Shutterstock.com

nose, plan the treatment and confirm biomechanics
in a far more in-depth way than ever before, orthodontics is now catching up with the high-tech world
we live in—it is twenty-first-century orthodontics.
When aligners were first introduced to the market,
there were some limitations and we could only
treat mild malocclusions. However, aligner therapy
has come of age and is now a genuine appliance
system with which we can treat the majority of
malocclusions.
At the moment, however, aligner therapy is still a
fairly expensive form of orthodontics. Thus, I hope
that improvements in materials and 3-D printing will
render manufacture and the product itself more

cost-effective. For example, 3-D printers could allow
individual practices to print their own aligners in the
future.
Overall, with technological advancements and increasing patient acceptance, we will be able to treat
pretty much everything in the future in my view.
How have developments in the European and
the overseas market differed?
Dentistry as a profession is very conservative and
dentists in the US, for example, are perhaps a bit
more progressive. However, with regard to aligners,
I no longer really see a great difference between
Europe and America. The movement is global and
I suspect the advancements we are now seeing in

ortho
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2016

[50] =>

| feature interview

Europe will match those in America and Asia, where
aligner therapy is also very popular. There are always
regional differences, also partly related to legal
restrictions, but the trend towards aligner therapy is
a global phenomenon.
How does the EAS address the current trends in
orthodontics?
Aligner therapy has seen huge advancements
over the past decade, with an increasing number of

“...aligner therapy opened the door for a huge
cohort of patients who would not have considered
orthodontic therapy in the past...”
manufacturers offering different systems today.
Thus, the main motivation behind the foundation
of the EAS was to establish a neutral body—an international society that is independent of any aligner
company and open to all dentists using aligners for
orthodontic treatment.
The work of the EAS is characterised by three cornerstones. The first is education, namely arranging
conferences and regional meetings and introducing
clinical online forums, through which members
can interact and share experiences and ideas. The
second column of the EAS’s philosophy is communication. We aim to be a neutral organisation that
patients can turn to for comprehensive information
about aligner therapy and that members can consult for guidelines. Research is our third column,
which is currently lagging behind. Eventually, we

50 ortho
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hope to have our own aligner journal or magazine
and grant annual awards for excellence in aligner
therapy.
With the help of our sponsors, the EAS will grow
and become an international umbrella organisation
to help promote education and research and development for aligner therapy.
The EAS is a fairly young organisation and hosted
its first congress on 13 and 14 February in
Vienna. What was the idea behind this event?
The EAS’s primary objective is education because, obviously, education underpins every profession and without it we simply stagnate. Therefore, we decided that our first event should be a
congress held in the heart of Europe offering a
broad spectrum of informative lectures and a
showcase of different systems and products. At
the first congress in Vienna, internationally distinguished speakers shared their views and expertise about aligner therapy. Moreover, the event
offered manufacturers an independent forum for
exhibiting their solutions.
Can dental professionals look forward to another
EAS congress next year?
Based on the success of the inaugural event over
the past weekend, we definitely want the congress
to become a regular event in the calendar. While we
are planning to hold the EAS congress every two
years, we will be organising smaller regional forums
on a continuous basis throughout every year.
Thank you very much for the interview.

[51] =>

POp!
®

[52] =>

products
comprehensive dentistry services

GC Orthodontics Europe—a new player in orthodontics

The global dental specialist GC corporation has
expanded into the orthodontic market and has
formed a new company, GC Orthodontics Europe
GmbH.
GC Corporation, which is active throughout the
world, is expanding its field of expertise and adding
another powerful element to its portfolio with the
creation of GC Orthodontics Europe GmbH. This
move supports the philosophy of the GC group in
providing high quality products and excellent service in orthodontics, with the desired aim of offering
the greatest possible benefit for dentistry along
with optimum practitioner and patient satisfaction.
The foundation of GC Orthodontics Europe GmbH
(GCOE) brings the GC Corporation closer to its goal
of offering comprehensive dentistry services at the
highest level. As one of the world’s leading dentistry
firms, GC has been providing product solutions to
the entire world for over 95 years, and now will be
doing the same for orthodontics. Helping improve
overall human health is one of the main principles of
GCOE, which is committed to the values and philosophy of GC Corporation worldwide. Combining tradition and progress are just as important as high
standards in products and services.
GC Orthodontics Europe GmbH is based in the
German town of Breckerfeld and will be distributing
the new product range directly in Germany and
France, and will be working with exclusive official
dealers in the rest of Europe, the Middle East and
Africa. The company will benefit from close cooperation with its distribution partners in the individual countries with superior knowledge of their own
markets and experience they have accumulated
over the years.

52 ortho
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“Our goal is to offer a comprehensive package of
services to orthodontics, and provide our clients
with quality management, product advice and
training programmes for all orthodontic personnel. We will do this by offering top-quality customised product solutions, supported by innovative
ordering options and hi-tech communication”,
commented Jacques Peucat, European sales
manager of GC Orthodontics Europe GmbH.
GC have partnered with the long-established expertise of the leading Japanese company Tomy
Inc., a byword for innovation, efficiency and quality.
‘Made in Japan, assembled in Germany’; while
most of the products will originate from Japan,
some manufacturing and all distribution activities
will take place in Germany, a great advantage for
Europe. The use of the most innovative materials
and technology will not only ensure that the highest
processing and reliability standards are met, but
will also allow patients of all ages undergoing orthodontic treatment to enjoy a comfortable and attractive outcome.
Jacques Peucat: “We offer a unique symbiosis of
quality, service and know-how, and our objective is
to transform the enthusiasm for orthodontics that

we share with our clients into joint success. This
passion is what drives us towards the global future
of orthodontics.”
The product portfolio consists primarily of modern
solutions for fixed orthodontics, including the
self-ligating bracket systems in the Experience
line. The brackets in this range include Experience
Metal, Experience Ceramic and Experience Lingual, along with the Experience Mini Metal brackets, the attractive rhodium-coated versions of
which are a real innovation in fixed orthodontics;
scarcely higher than a conventional bracket, they
are a highly effective combination of aesthetics,
function and comfort.
The clients and partners of GC Orthodontics Europe GmbH will also benefit from one of GC Corporation’s key principles: the company will from the
very beginning operate to the highest quality
standards in all areas—products, services, environmental protection and sustainability—in this
new area of activity—orthodontics.
Find your local dealer at www.gcorthodontics.eu/
GC/en/content/european-organization
GC Orthodontics Europe GmbH
Harkortstraße 2
58339 Breckerfeld
Germany
info-de@gcorthodontics.eu
www.gcorthodontics.eu

[53] =>

diagnosis of bruxism

An easier way to detect bruxism
Bruxism is one of the most common parafunctions,
commonly associated with sleep disorders. While
existing home testing devices are expensive and not
patient friendly, Bruxlab makes it possible to detect
bruxism in a cheap and easy way. The Dutch company
has developed diagnostic tools to record and quantify
any grinding sounds using machine learning, mobile
app technology and wearables.
Clinical signs of bruxism include excessive tooth
wear, sensitive teeth, headaches and fatigued jaw
muscles in the morning. However, sleep bruxism can
stop spontaneously and may not be chronic. A dentist can therefore not determine whether there is
active sleep and chronic bruxism by using conven-

tional ways of diagnosing sleep bruxism. Dentists
can now track patients using Bruxlab’s DoIGrind app
to see if there is active bruxism and if it is chronic.
The so-called Bruxsticker makes it possible to measure movement of the lower jaw during sleep. An
integrated nano-accelerometer and Bluetooth chip,
in combination with the app, record and filter
tooth-grinding sounds over multiple nights.
The new idea behind Bruxlab is an algorithm that can
filter any tooth-grinding sounds and tooth contact
sounds. The latter often indicate the beginning of a
clenching episode. The Bruxlab software validates the
sounds using the gold standard, polysomnography,
better known as a sleep test. This test will tell dentists

if there was muscle activity at the same time that a
grinding sound was detected. The device on which the
app is loaded is placed next to the bed and records and
filters any tooth-grinding sounds. On average, the
Bruxlab technology reduces eight hours of sleep to five
minutes of relevant sounds. The sounds are uploaded
to the cloud, where the dentist can listen to them.
Bruxism can now be easily detected thanks to Bruxlab.
Bruxlab
www.bruxlab.com

bruxism treatment

A cost-effective and custom solution for bruxism
In the U.S. alone, bruxism affects 10 per cent of people and as many as 15 per
cent of children, according to the American Sleep Association. Once this oral
habit has been identified, dentists usually prescribe a night guard or splint.
However, many types of night guards exist on the market that do not fit perfectly
owing to the hard acrylic material from which they are manufactured. Furthermore, while custom-made occlusal guards are the best permanent solution,
not every patient affected by bruxism can afford such an expensive
mouth guard. Insurance may cover a night guard only once
in the patient’s lifetime. Therefore, many cases of
bruxism go untreated, causing continued permanent damage to patients’ teeth.
U.S.-based Akervall Technologies offers an effective custom-made and cheaper solution: the SOVA
Night Guard, the thinnest over-the-counter night
guard on the market made of thermoplastic material. While
the SOVA Night Guard is only 1.6 mm thick, it has been designed to
withstand 30 per cent more impact than a conventional mouth guard. Patients
have reported that within the first week of wearing the night guard, the pain
caused by bruxism or temporomandibular joint dysfunction (TMD) was significantly reduced or stopped. Moreover, they have remarked on SOVA’s stability
and thinness, as well as the ease of drinking and talking while wearing it.
The technology behind the SOVA Night Guard is called Diffusix and it works with
unique perforations and special crumple zones that prevent grinding forces
from travelling to the teeth, relieving pain and reducing the risk of dental injury.
When a SOVA Night Guard is properly fitted, perforations oscillate on impact to
diffuse grinding forces and guide those forces into the crumple zones. The
perforations also allow for a true custom fit and natural flow of air and saliva.
The SOVA Night Guard is made from a tough thermoplastic polymer material
with a high tensile strength that is biocompatible, biodegradable and BPA-free.

The night guard starts as a flat horseshoe shape. After immersion in 130 °F
(54 °C) water, the material becomes pliable. The night guard is then molded
against the teeth until it hardens. Thus, rather than requiring taking an impression and sending it to the dental laboratory, the SOVA Night Guard can be
molded in the office in under 5 minutes to provide the patient with an immediate
solution. The appliance can be remolded up to 20 times. SOVA also works with
orthodontics. As the teeth are moving, the night guard can be
easily adjusted.

Akervall Technologies
1512 Woodland Drive
Saline, MI 48176
USA
www.sovanightguard.com

ortho
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2016

[54] =>

products
clear aligner therapy

ClearCorrect clear aligner therapy discreetly improves crowding and
constricted archforms

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Today, there are more options available to those seeking orthodontic services than ever before thanks to advances in clear aligner therapy. The
rising popularity of ClearCorrect and other clear aligner providers has
spiked over the past decade, and is only expected to continue its aggressive
growth trajectory. According to a recent Azoth Analytics research report,
the global invisible braces market is expected to grow at an annual rate of
12.16 per cent from 2016 to 2021. Now more teens and adults are seeking
orthodontic treatment for a wide variety of reasons, such as, improved
aesthetics, affordability, and orthodontic relapse.
ClearCorrect aligners are more affordable than leading competing brands,
allowing doctors to pass greater savings to their patients. Doctors can
easily submit digital intraoral scans and manage their cases on the user-
friendly website while also working with a designated customer service
specialist. ClearCorrect is suitable for most treatment goals from minor
cases to more advanced crowding and spacing complaints.

Dr Mark J. Bentele successfully treated a patient’s chief complaint of adolescent orthodontic relapse with ClearCorrect. The patient had a Class I
right, Class I left molar relationship, with a Class I right, end-on Class II left
canine relationship. Dr Bentele submitted the case to ClearCorrect and
requested an improved upper and lower midline, and also requested an
idealized overjet, improved overbite, and improvement of the constricted
arch forms while maintaining molar relationship (Figs. 1–3). Proclination
of the mandibular incisors was requested and #11 be distained into a
proper Class I relationship, and all spaces were to be closed.

54 ortho
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The ClearCorrect treatment plan estimated 24 sets of aligners. The patient
was compliant wearing each set of aligners for three weeks (at least
22 hours a day). At the start of treatment, facial translation of premolars
and canines occurred, and then engagers were placed on teeth Nos. 7, 10,
22 and 27 and 0.3 mm IPR was performed on the mesial/distal #27. After
the engager placement, the patient received the fifth set of aligners and
was also given his sixth set to take home. Next to complete the patient’s
total treatment, a contact check on tooth #27 was performed to ensure
patient compliance, and teeth Nos. 22 and 23 were correctly aligned.
The patient progressed more quickly than originally planned, and only
needed 16 sets of aligners as opposed to 24 sets. At the end of the ClearCorrect treatment, all objectives were accomplished and the patient was
instructed to wear retainers at night time indefinitely (Figs. 4–6). Upon
treatment completion, Dr Bentele’s patient was very happy with the results and the effectiveness of ClearCorrect clear aligner therapy.
Founded in 2006 by dentists, ClearCorrect understands the needs of
both doctors and patients, and has been proven effective for more than
20,000 doctors worldwide. Doctors find that ClearCorrect is easy to
implement into their practice with convenient access to online optional
training with marketing kits at their fingertips. The company designs,
manufactures and supports its products out of its headquarters based
in Round Rock, Texas, USA.
Teens and adults can benefit from clear aligner therapy due to the aesthetic, affordability, shorter treatment period, and lasting results.
ClearCorrect
21 Cypress Blvd, Suite 1010
Round Rock, TX 78665
USA
info@clearcorrect.com
www.clearcorrect.com

[55] =>

[56] =>

products
photobiomodulation

OrthoPulse from Biolux Research shortens
duration of orthodontic treatment
‘How long will it take?’ is the ever-recurring question most orthodontists hear during orthodontic
treatment, especially with adults. An increasing
number of patients are seeking shorter orthodontic treatment times. Various techniques exist to
accelerate tooth movement and thereby shorten

Fig. 2: OrthoPulse with charging box.

treatment time. Most of these approaches are
invasive and require additional surgical interventions, reducing their acceptance by patients and
orthodontists. One method that is gaining traction
due to its convenience and effectiveness is the
acceleration of orthodontic tooth movement
through photobiomodulation with an OrthoPulse,
a device from Canadian company Biolux Research Ltd.
What is photobiomodulation?
Photobiomodulation (PBM), also known as lowlevel light therapy (LLLT), is non-invasive and uses
low energy lasers or light-emitting diodes (LED) to
modify cellular biology by exposure to light in the
red to near-infrared (NIR) wavelength range between 600 and 1,000 nm. This NIR light is almost
invisible to the human eye; however it has been
shown to provide a therapeutic benefit by increasing the metabolic activity of bone and soft tissues.
PBM leads to a non-thermal photochemical reaction in the irradiated cells, of which the effect on
the mitochondria should be particularly highlighted. Back in the 1930s, German chemist and
Nobel laureate Otto Wartburg discovered the effect of specific light frequencies on mitochondrial
activity.

56 ortho
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This therapy is used in dentistry for pain relief,
dentinal hypersensitivity, treatment of craniomandibular dysfunction (CMD), improving implant stability, and treating mucositis, as well as in the acceleration of orthodontic treatments.
PBM therapy is painless and free of side effects, as
shown in the application of other medical fields,
such as acceleration of wound healing, physiotherapy or hair loss.
Since 2003, Biolux Research Ltd. focuses on photobiomudulation in the field of
dentistry – or strictly speaking,
the acceleration of bone regeneration.
Based on its experience in the
areas of bone attachments
and bone remodelling, Biolux entered the market
with OrthoPulse (Fig. 2), a
device for the acceleration of
orthodontic treatment that can be used in combination with any fixed appliance, whether it is buccal or
lingual, or treatment with aligners. The intraoral
device is used daily by the patient and emits via the
LEDs a NIR with a wavelength of 850 nm, which irradiates the buccal surface of the jaw towards the
parodentium in order to accelerate bone remodelling. The energy density is 19.5 J / cm2 for a daily use
of 5 minutes per jaw.

Fig. 1: Photons penetrate the bone and soft tissue
around the root of the teeth and stimulate the mitochondrial enzymes, which enhances the production of ATP.
The increased energy enables the acceleration of tooth
movement.

After providing the patient with instructions in the
practice, he uses the device once a day for 5 minutes per treated jaw. Accidental misuse by the
patient is avoided thanks to the automatic start of
the session once the device is in the mouth and
stops once the treatment has been completed. The
OrthoPulse smartphone app has been to provide
doctors and patients with OrthoPulse treatment
compliance at a glance, by tracking of the overall
patient’s treatment consistency and percentage
compliance. The continuous monitoring of the
treatment by the orthodontist is ensured in the
time between inspections.
In addition to shortening the duration of the
treatment up to of 50 % through the use of
OrthoPulse, patients report significantly reduced

Fig. 3: The app enables the treating orthodontist to check whether the treatments are actually carried out.

[57] =>

pain during the first days after the wire change or
adjustment, as well as change of aligner.
Leading research institutions such as The Forsyth
Institute, Cambridge, USA, and Kyung Hee University, Seoul, Korea are now examining the effects of
PBM.
Research by Chiari et al at Boston University,
studied the effect of PBM-induced tooth movement using extraoral transcutaneous phototherapy on the rat periodontium. The results showed a
2.8–3.7 x faster tooth movement.
Clinical research on the effect of PBM during
orthodontic treatments provided astonishing
results.

Treatment with fixed appliances
·· No clinically significant root resorption1
·· 46 % increase in rate of space closure in adults;
28 % increase in rate of space closure2 in adolescents compared to control
·· 54 % reduction in time to achieve anterior alignment3
·· 2.3x faster mean alignment rate4
·· No significant changes in root resorption greater
than .32 mm5
Treatment with aligners
·· 66 % reduction in the average duration per
aligner during OrthoPulse, treatment as com-

pared to the conventionally recommended
aligner wear duration6
·· No measurable root resorption over 6 months7
Editorial note: Complete list of references is available
from the publisher and at www.orthopulse.com.

Biolux Research Ltd.
220-825 Powell St.
Vancouver, BC, V6A 1H7
Canada
www.bioluxresearch.com

digital imaging

Planmeca ProMax 3D units—Ideal for imaging patients with braces
Planmeca ProMax 3D is a CBCT product family
consisting of exceptional all-in-one imaging units.
The intelligent units support several different imaging modalities and provide all needed specialist tools.
As a reflection of their suitability for orthodontics,
three of the Planmeca ProMax 3D units—Classic,
Mid and Max—have now been certified for use
with the suresmile treatment management system.
Planmeca ProMax 3D units have been designed to
meet the strictest of requirements in maxillofacial
imaging. They support three different types of 3-D
imaging (CBCT, 3-D face photo and 3-D model scan),
and also extraoral bitewing, cephalometric and digital panoramic imaging. This flexibility between 2-D
and 3-D allows clinics to optimise their imaging procedures, and select the techniques that work best
with each case—at an optimal patient dose.
The Braces imaging protocol of Planmeca ProMax
3D units is tailor-made for orthodontics, as it allows
users to acquire a low dose CBCT image, which ac
curately shows the metal brackets on braces. With
powerful artefact removal algorithms used in image
reconstruction, the units produce images that reveal
the exact position of roots in relation to bone.
The CBCT units’ stable support system helps patients remain completely still during imaging. This
is especially important when acquiring high contrast images as part of orthodontic treatments.
Certified for use with suresmile
The Planmeca ProMax 3D Classic, Mid, and Max
CBCT units are now certified for use with the suresmile treatment management system by OraMetrix.

The suresmile system has been designed to enable
orthodontists to visualise and simulate multiple diagnostic set-ups and design customised archwires
for every patient.

meca Ultra Low Dose protocol available in all Planmeca P roMax 3D X-ray units reduces the effective
patient dose in CBCT imaging significantly—without
a statistical reduction in diagnostic image quality.

Fig. 1: Traditional CBCT image.

Fig. 2: CBCT image with the Braces imaging protocol.

The accuracy of patient scans plays a critical role
in maximising the effectiveness of the suresmile
system. Combining the system with a CBCT unit
allows the efficient visualisation and virtual manipulation of teeth and their roots. The orthodontic
braces protocol of Planmeca ProMax 3D units has
been optimised for use with the suresmile treatment management system.

At best, this means lowering patient doses to levels
below even that of traditional 2-D panoramic imaging.
With suresmile-certified Planmeca ProMax 3D
units and the Planmeca Ultra Low Dose protocol,
patients can benefit from CBCT imaging and three-
dimensional diagnostic accuracy in orthodontic
treatments with a significantly lower patient dose
than in traditional imaging.

See more at a lower dose
The effective patient dose of CBCT imaging is closely
related to the protocol used for scanning. Planmeca
has established itself as the industry leader in pioneering ultra low dose imaging. The innovative Plan-

Planmeca Oy
Asentajankatu 6
00880 Helsinki
Finland
www.planmeca.com

ortho
57
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2016

[58] =>

products
vibration therapy

AcceleDent Aura—Vibration device for orthodontic treatment
The most common concerns that prevent some
patients from commencing orthodontic treatment
are the length of treatment time and pain. Orthodontists and patients alike have found a solution
to these treatment barriers with AcceleDent Aura,
a prescription-only, Class II medical device employing SoftPulse Technology, which has been
proven to accelerate orthodontic treatment by as
much as 50 per cent and reduce pain associated
with treatment. AcceleDent has clearance in
more than 40 countries and the body of research
supporting its safety and efficacy continues to
grow as more orthodontists and patients report
positive results with this non-invasive, accelerated-treatment technology.
Medical literature has shown that the application
of low-level pulsatile forces to bone can restore
balance to the bone deposition and resorption
cycle.1, 2 While their exact mechanisms of action
are not understood, medical devices that transmit
micro-pulses have been shown to prevent bone
breakdown and to increase bone density in animal
and human studies. Micro-pulse therapy continues to be researched as a viable treatment option
for patients with osteoporosis and bone fractures.
Orthodontic tooth movement is the result of controlled manipulation of the bone deposition and
resorption cycle using arch wires, springs, aligners and other appliances to apply force to teeth,
which in turn alters the environment of the alveolar
bone. Applying micro-pulse technology, such as
that used in AcceleDent, in conjunction with
orthodontic appliances has been clinically
shown to accelerate this process. Published
in the peer-reviewed Seminars in Orthodontics, this prospective, double-blind, randomised,
sham-controlled trial has demonstrated that
gentle, non-invasive vibration, applied as an adjunct to treatment for 20 minutes per day, significantly increases the rate of tooth movement.3
The AcceleDent Aura device incorporates an
activator, which generates the micro-pulses, and
a mouthpiece, which comes in large- and smallarch sizes. The patient turns on the activator and
bites down on the mouthpiece for 20 minutes
daily during the course of orthodontic treatment.
Small and lightweight, AcceleDent is designed for
hands-free use and is held in place simply with bite
pressure. This enables patients to engage in other
activities, such as reading, driving, watching

58 ortho
1 2016

television or using a computer, which provides
some convenience for patients in scheduling the
daily treatment.
A second common barrier to orthodontic treatment is pain. As evidenced by a randomised controlled trial published in the peer-reviewed journal Angle Orthodontist, micro-pulse vibration
devices, such as AcceleDent, significantly lower
orthodontic treatment pain scores for overall pain
and biting pain.4 A reduction in discomfort is highly
attractive to orthodontic patients and likely aids in

a skeletal Class II with infra-labioversion of the
maxillary canines and a steep mandibular plane
angle. All four of the patient’s third molars were
removed prior to aligner treatment. Ojima’s assessment of this patient called for the patient to
change aligners every 14 days over 30 months;
however, the patient was unwilling to undergo
treatment for that length of time. To accelerate
her treatment, Ojima prescribed AcceleDent with
instructions to change aligners every five days,
enabling the patient to complete treatment in
18 months while experiencing no discomfort.5
Faster orthodontic treatment
results have also been demonstrated with fixed appliances, as
illustrated by Dr Sharon Orton-Gibbs.
Reporting on the first extensive single-centre treatment experience with delivery of pulsatile forces, Orton-Gibbs published the results of
predicted and actual treatment times for 14 control patients treated with fixed appliances and
14 AcceleDent patients treated with fixed appliances. As published in the Journal of Clinical Orthodontics, Orton-Gibbs found that the AcceleDent group completed treatment 33.5 per cent
faster than their predicted treatment times, saving
an average of 6.23 months of treatment time.6
Conclusion
AcceleDent Aura enables orthodontists to remove barriers to treatment and give patients
what they want—faster orthodontic treatment
with reduced discomfort—while achieving sophisticated clinical results. The peer-reviewed
evidence and clinical reports prove that AcceleDent Aura accelerates orthodontic treatment by
as much as 50 per cent and reduces pain. There
are tens of thousands of AcceleDent patients
across the world who, along with their orthodontists, have reported high satisfaction with their
accelerated treatment.

compliance with the daily AcceleDent regimen and
contributes to patient satisfaction.
Dr Kenji Ojima has treated more than 400 aligner
cases with AcceleDent, including complex orthodontic cases. The Journal of Clinical Orthodontics
published the results of Ojima’s treatment of a
26-year-old female patient who was diagnosed as

Editorial note: A complete list of references is available from the publisher.
OrthoAccel Technologies, Inc.
6575 West Loop South, Suite 200
Bellaire, TX 77401
USA
www.acceledent.com

[59] =>

Temporomandibular Disorders (TMD) and Occlusion
A 2-day course training in Dubai (UAE)

This course consists of 2 intensive days in Dubai
with lectures, hands on practice, and mentoring.

Online access to our
library of Lectures & Clinical Videos

Registration information:

www.TribuneCME.com
Curriculum fee: €1,350
tel.: +49-341-484-74134 | email: request@tribunecme.com

Tribune Group GmbH is an ADA CERP provider. ADA CERP is a service of
the American Dental Association to assist dental professionals in identifying
quality providers of continuing dental education. ADA CERP does not
approve or endorse individual courses or instructors, nor does it imply
acceptance of credit hours by boards of dentistry.

12

C.E.

CREDITS

Certificates will be
awarded upon completion

Tribune Group GmbH is designated as an Approved PACE Program Provider by the Academy
of General Dentistry. The formal continuing dental education programs of this program
provider are accepted by AGD for Fellowship, Mastership and membership maintenance
credit. Approval does not imply acceptance by a state or province board of dentistry or AGD
endorsement. The current term of approval extends from 7/1/2014 to 6/30/2016.
Provider ID# 355051.

[60] =>

products
new abrasion technique

Easy bonding of orthodontic brackets
Abrasion has long been discussed as a treatment in all areas of dentistry.
With AquaCare, UK-based Velopex International has introduced an innovative and contactless way to abrade and polish teeth and orthodontic appliances. The unit combines four powder cartridge systems with an easy-touse multi-function handpiece–that can even double via the foot control as
a 3-in-1. AquaCare is capable of delivering abrading and prophylaxis media
all via the same handpiece. Among the many applications areas, orthodontists can use AquaCare for bonding orthodontic brackets. The enamel of the
tooth to be treated can be ‘etched’ to the exact size of the orthodontic
bracket at the place of attachment. This is achieved by holding the cutting
nozzle 2 mm above the surface of the tooth and gently moving it in a circular
motion over the required area. This will result in a dry ‘etched’ surface, ready
to accept the bonding agent. The risk of saliva contamination is greatly reduced because the aluminium oxide dries the surrounding mucosa. The

same technique can be used to clean the orthodontic brackets.
Therefore, AquaCare is a superior tool for incognito lingual brackets as it
is able to reach difficult internal surfaces in order to clean and attach the
brackets.
Medivance Instruments Ltd.
Barretts Green Road
London
United Kingdom
www.velopex.com

digitally planned retainer

POP expansion screws

MEMOTAIN from CA DIGITAL

Perfect Orthodontic Performance

CA DIGITAL is your direct contact and service partner in all areas of digital orthodontics and clinical applications. We assist you with all questions relating to
precise digital treatment planning, offering you individual co-operation options
and product solutions. Our latest innovation is the new MEMOTAIN nitinol
CAD/CAM retainer. This retainer is digitally planned and precisely machinemade, offering the highest precision, best fit and user comfort.
In contrast to hand-bent, conventional lingual steel retainers, MEMOTAIN retainers are produced and computerised to fit the individual tooth shape of the
patient. The teeth are fixed dynamically and perfect wearing comfort is achieved
through matching to the patient’s teeth. Owing to machine manufacture, the wire
is not bent and thus not weakened. Predetermined breaking points are eliminated. Therefore, CA DIGITAL provides a 24-month breakage warranty.

The innovative and biomechanical orthodontic expansion screw POP is made of
stainless steel and biomedical techno polymer. The male screw is not in contact
with the orthodontic acrylic resin; the function of the screw will not be influenced
by the quality of the technical procedure and a non-compliant curing time.
Continuous expansion movement: the high pressure injection of the polymer
allows the perfect copy of the male thread of the screw, thus ensuring a steady
expansion transmission without the risk of undesired turning back in the
mouth. The self-centring rectangular guides ensure a biomechanical and
absolutely controlled symmetrical expansion. The flat shape of the guides and
their flexibility allow the gradual release of the expansion with a physiological
orthodontic movement. The flexibility of the screw allows the adjustments of
any dental regress due to inconsistent use of the appliance by the patient, thus
being very effective with holding devices following a rapid expansion treatment. The high adaptability of the appliance enables a comfortable application in the mouth in the days following reactivation. Two embossed arrows on
the body indicate the direction of opening. When using a colour of acrylic resin
similar to the polymer body, a white arrow provided with the plastic placement
tab may be easily applied to make the direction of activation visible.
The placement plastic tab, made of two pieces combined with a unique geometry, allows perfect protection of the holes from the acrylic resin during the
packing procedure and facilitates the removal after
the curing cycle. The screw body is available in
five colours.

CA DIGITAL GmbH
Willetstraße 10
40822 Mettmann
Germany
www.ca-digit.com

Leone S.p.A.
Via P. a Quaracchi, 50
50019 Sesto Fiorentino, Florence
Italy
info@leone.it

60 ortho
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[61] =>

register for

FREE

– education everywhere
and anytime
– live and interactive webinars
– a focused discussion forum
– free membership
– no travel costs
– no time away from the practice
– interaction with colleagues and
experts across the globe
– a growing database of
scientific articles and case reports
– ADA CERP-recognized
credit administration

www.OTStudyClub.com

Ortho Tribune Study Club

Join the largest
educational network
in orthodontics!
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providersof continuing dental education.
ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

[62] =>

| meetings Nobel Biocare Global Symposium

Where innovation
comes to life
World-class speakers, hands-on instruction, master
classes, forums and social networking opportunities,
all in the heart of one of the greatest cities in the
world. Between June 23 and 26, the fabled Waldorf
Astoria in Manhattan will be hosting the Nobel Biocare Global Symposium under the banner “Where innovation comes to life.”

The symposium’s four-day program will be based on
three main themes: refining and enhancing treatment,
digital dentistry and achieving clinical excellence in
challenging situations. Each theme has a complete
schedule of its own, including lectures, master classes
and practical sessions. Should attendees choose to follow only one theme, the symposium schedule allows
them to be a part of every related session.
If, on the other hand, delegates would like to pick
and choose between the different themes and attend
individual sessions of special interest in several (or all)
of the themes, Nobel Biocare gives them the opportunity to design their own learning program.

contact
Nobel Biocare
Balsberg
Balz-Zimmermannstr. 7
8302 Kloten
Switzerland

62 ortho
1 2016

In addition to a theme-related agenda intertwined
with independent study opportunities, the company
is arranging a compelling array of forums, including
an innovation assembly and a full-day compromised
patient forum. Other forums will cover the company’s
Partnering for Life program, through which Nobel
Biocare helps dental professionals achieve their goals,
the All-on-4® treatment concept and the dental laboratory workflow. A new generation of dental professionals will also have their own platform at the event’s
NEXT GEN forum.

Getting to know each other
After a busy first day of lectures, master classes
and hands-on sessions, a welcome cocktail on June
23 will provide the perfect opportunity to unwind
and network with colleagues from around the world.
Attendees will be able to raise a glass, enjoy some
food and see a display of innovative Nobel Biocare
products in the beautiful, historical setting of the
Waldorf Astoria.
On the evening of June 24, Nobel Biocare will be
hosting the symposium’s reception off-site at an
exciting venue, yet to be revealed. It is set to be an evening to remember with an inspiring blend of diversion
and education.

By popular demand
The Scientific Chairmen for the Nobel Biocare
Global Symposium are Drs Peter Wöhrle (USA) and
Bertil Friberg (Sweden). They recently announced
that—for the first time at a Nobel Biocare dental
event—registered attendees will be able to have a
direct impact on the program by voting for various
topics and speakers on the event’s website. The results
will be revealed a few weeks before the symposium.
With world-class lecturers and thousands of dental
professionals from around the world exploring the
future of dental implants together, the 2016 Nobel
Biocare Global Symposium promises to be an incomparable experience for everyone involved.
Registration for the symposium is open at:
www.nobelbiocare.com/global-symposium-2016_

[63] =>

agence-koeln.de

4th Scientific

18th and 19th November 2016
Cologne, Germany
The 4th Scientiﬁc Congress for Aligner Orthodontics
will take place on 18th and 19th November 2016
at the Cologne Gürzenich. With more than 500
participants and over 30 exhibitors, the DGAO
Congress is the worlds largest, independent
aligner congress.

www.dgao.com

[64] =>

| meetings events

International Events
2016
American Association of Orthodontists
29 April–3 May 2016
Orlando, USA
www.aaoinfo.org
Dental Digital Marketing Conference
29–30 April 2016
Dallas, USA
www.dentalmarketingconference.com
11th CAD/CAM & Digital Dentistry International
Conference
6–7 May 2015
Dubai, UAE
www.cappmea.com

3rd MIS Global Conference:
360° IMPLANTOLOGY
26–29 May 2016
Barcelona, Spain
www.mis-implants.com
Nobel Biocare Global Symposium
23–26 June 2016
New York, USA
www.nobelbiocare.com/global-symposium-2016/
European Orthodontic
Society 2016 Congress
11–16 June 2016
Stockholm, Sweden
www.eos2016.org
Asia Pacific Orthodontic Society
10th Asia Pacific Orthodontic Conference
1–3 September 2016
Nusa Dua, Bali, Indonesia
www.10apoc.com
FDI Annual World Dental Congress
7–10 September 2016
Poznan, Poland
www.fdi2016poznan.org
Canadian Association of
Orthodontists Annual Session
15–17 September 2016
Charlottetown, Prince Edward Island, Canada
www.cao-aco.org
ROYAL ESTHETICS
13th ESCD Annual Meeting
22–24 September 2016
Krakow, Poland
www.royalesthetics.eu

Orlando. Photo: Songquan Deng / Shutterstock.com

64 ortho
1 2016

Greek Association for Orthodontic Study
and Research
14th Panhellenic Orthodontic Congress
23–25 September 2016
Athens, Greece
www.eogme.gr

[65] =>

submission guidelines about the publisher

submission guidelines:
Please note that all the textual components of your submission
must be combined into one MS Word document. Please do not
submit multiple files for each of these items:
·· the complete article;
·· all the image (tables, charts, photographs, etc.) captions;
·· the complete list of sources consulted; and
·· the author or contact information (biographical sketch,
mailing address, e-mail address, etc.).

|

Image requirements
Please number images consecutively throughout the article
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certain images are grouped together, then use lowercase letters
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Please place image references in your article wherever they
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If you do not directly refer to the image, place the reference
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In addition, please note:

In addition, images must not be embedded into the MS Word
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the article as long or as short as necessary.
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usually entails a topic for which each part can stand alone be- space should there be room available.)
cause it contains so much information.
Also, please remember that images must not be embedded into
In short, we do not want to limit you in terms of article length, the body of the article submitted. Images must be submitted
so please use the word count above as a general guideline and if separately to the textual submission.
you have specific questions, please do not hesitate to contact us.
You may submit images via e-mail, via our FTP server or post
Text formatting
a CD containing your images directly to us (please contact us
We also ask that you forego any special formatting beyond the for the mailing address, as this will depend upon the country
use of italics and boldface. If you would like to emphasise certain from which you will be mailing).
words within the text, please only use italics (do not use underli
ning or a larger font size). Boldface is reserved for article headers. Please also send us a head shot of yourself that is in accordance
Please do not use underlining.
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with your article.
Please use single spacing and make sure that the text is left justified. Please do not centre text on the page. Do not indent para- Abstracts
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not add tab stops.
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you automatically. There are menus in every programme that will biographical sketch may precede the contact information
enable you to do so. The fact is that no matter how carefully done, if you provide us with the necessary information (60 words
errors can creep in when you try to number footnotes yourself.
or less).
Any formatting contrary to stated above will require us to remove
such formatting before layout, which is very time-consuming.
Please consider this when formatting your document.

Questions?
Magda Wojtkiewicz (Managing Editor)
m.wojtkiewicz@dental-tribune.com

ortho
65
1
2016

[66] =>

| about the publisher imprint

ortho
international magazine of

orthodontics

Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com
Managing Editor
Magda Wojtkiewicz
m.wojtkiewicz@dental-tribune.com
Contributing Editors
Claudia Duschek
c.duschek@dental-tribune.com
Kristin Hübner
k.huebner@dental-tribune.com

Marketing Services
Nadine Dehmel
Sales Services
Nicole Andrä
Executive Producer
Gernot Meyer
International Media Sales

Marc Chalupsky
m.chalupsky@dental-tribune.com

Antje Kahnt (Account & Product
Manager Events/today)
a.kahnt@dental-tribune.com

Designer
Josephine Ritter

Matthias Diessner (Key Accounts)
m.diessner@dental-tribune.com

Copy Editors
Sabrina Raaff, Hans Motschmann

Melissa Brown (International)
m.brown@dental-tribune.com

International Administration
Chief Financial Officer
Dan Wunderlich
Business Development Manager
Claudia Salwiczek-Majonek
Event Manager
Lars Hoffmann
Event Services
Esther Wodarski

Peter Witteczek (Asia Pacific)
p.witteczek@dental-tribune.com

International Offices
Dental Tribune International
Holbeinstr. 29, 04229 Leipzig, Germany
Tel.: +49 341 48474-302
Fax: +49 341 48474-173
info@dental-tribune.com
www.dental-tribune.com
Dental Tribune Asia Pacific Ltd.
Room A, 20/F,
Harvard Commercial Building,
105–111 Thomson Road, Wanchai,
Hong Kong
Tel.: +852 3113 6177
Fax: +852 3113 6199
Tribune America, LLC
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New York, N.Y. 10011, USA
Tel.: +1 212 244 7181
Fax: +1 212 244 7185

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w.mageswki@dental-tribune.com
Hélène Carpentier (Europe)
h.carpentier@dental-tribune.com
Barbora Solarova (Eastern Europe)
b.solarova@dental-tribune.com

Printed by
Löhnert Druck
Handelsstraße 12
04420 Markranstädt, Germany

Copyright Regulations
ortho international magazine of orthodontics is published by Dental Tribune International (DTI) and is published yearly. The m
agazine and all articles
and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable to prosecution.
This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to
check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited
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the opinion of the afore-mentioned, and do not have to comply with the views of DTI. Responsibility for such articles shall be borne by the author.
Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be
assumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or
faulty representation are excluded. General terms and conditions apply. Legal venue is Leipzig, Germany.

66 ortho
1 2016

[67] =>

Nobel Biocare Global Symposium
June 23–26, 2016 – New York

Where innovation comes to life

Register
now
nobelbiocare.com/global-symposium-2016

An experience beyond the ordinary

Design your own learning experience

The Nobel Biocare Global Symposium 2016 program will
offer unparalleled clinical and scientific education, as well
as in-depth hands-on training. Held at the Waldorf Astoria
in New York, it’s a unique opportunity to experience how
innovation can come to life in your daily work.

Choose from numerous lectures, forums, master classes
and hands-on sessions – from over 150 of the best speakers
and presenters in the world. This must-attend event will
cover a vast variety of techniques and treatment solutions,
from diagnosis to treatment completion. Don’t miss this
opportunity. Sign up now and we’ll see you in New York!

Read more about the Symposium
© Nobel Biocare Services AG, 2016. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare. Please refer to nobelbiocare.com/trademarks for more information. Product images are not necessarily to scale. Disclaimer: Some products may not be regulatory cleared/released for
sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability.

[68] =>

Planmeca ProMax 3D Classic, Mid and Max units
®

Certified for use with suresmile

®

Combining Planmeca ProMax 3D Classic, Mid and Max units with
®

the suresmile treatment management system enables efficient
®

visualisation and virtual manipulation of teeth and their roots.

Ideal for orthodontics

• All imaging modalities: Panoramic • Cephalometric
• CBCT image • 3D photo • 3D model scan

• An ideal FOV for every diagnostic need
• Comprehensive Planmeca Romexis software for

The Braces imaging protocol is
optimised for use with suresmile

®

®

an efficient workflow

• 3D imaging with an even lower dose than panoramic imaging
with the Planmeca Ultra Low Dose™ imaging protocol

www.planmeca.com
www.suresmile.com

Planmeca Oy Asentajankatu 6, 00880 Helsinki, Finland.
Tel. +358 20 7795 500, fax +358 20 7795 555, sales@planmeca.com

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[cover] => ortho international No. 1, 2016

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Table of contents

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