ortho international No. 1, 2018

Cover / Editorial / Content / In-office welding by Nd:YAG laser / Surgical crown lengthening and botulinum toxin in the management of the orthodontic patient with gummy smile / Non-surgical treatment of a Class III malocclusion with missing lateral incisors / Six keys to effectively using alveolar corticotomy: A different perspective on surgically assisted tooth movement / Accelerated treatment modalities in clear aligner treatment / Indirect bonding: Digital technique vs conventional method / Hybrid Aligner Therapy / Digital smile design meets orthodontics: Full-day course closes second EAS Congress / Industry report / Meetings / Submission Guidelines / Imprint

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issn 1868-3207 • Vol. 3 • Issue 1/2018

ortho

international magazine of orthodontics

technique

Accelerated treatment modalities
in clear aligner treatment

industry report

Indirect bonding: Digital technique
vs conventional method

industry report

Hybrid Aligner Therapy

1/18

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!
y
a
d
o
T
r
e
t
egis

R

European Carriere
Symposium

September 20-22, 2018

Paris, France

World-Renowned Speakers

Dr. Luis Carrière

Dr. John Graham

More Speakers To Come!

Learn more about the

European Carriere Symposium
and register at CarriereSymposium.com

SYMPOSIA

© 2018 Ortho Organizers, Inc. All rights reserved. PN M1291 2/18

[3] => ortho_1_2018.indb

editorial

Dr Luis Carrière
Specialist in orthodontics and dentofacial
orthopaedics

The power of orthodontics
Dear Readers,
Sometimes as orthodontists we tend to simplify what
our specialty is about. Behind the simplicity—straightening teeth—there is a wide spectrum of facial, functional and physiological effects that we will generate,
all of them intimately interconnected. The patient’s soft
tissue is not self-supported, so an adequate volumetric amount of hard tissue underneath sculpts the facial
harmony. Orthodontics affects important dental, skeletal, functional, postural, physiological, articular, facial and
psychological areas for the patient. It is a powerful specialty in which the teeth are only a part.
As orthodontists, we are responsible for accomplishing
a balanced mid- and lower third of the face by managing
a correct functional and anatomical relation between the
maxillae and mandible, harmonising the position of the
teeth into an aesthetic interrelation, achieving a functional
occlusion. Ultimately, we sculpt the patient’s soft tissue,
providing facial proportion and a harmonic smile design.

In addition to aesthetics, correct functional occlusion
and tooth alignment will promote a healthy condition of
the maxillae and mandible, gingivae and teeth, preventing
many potential systemic diseases related to periodontal
or dental sickness.
This rare ability of our specialty to change the extrinsic
traits, the facial features, and maintain simultaneously the
facial icon, while enhancing the patient’s positive facial
features, can also achieve the opposite effect by promoting the patient’s negative facial features, maybe obstructing the patient’s airway or ending up with incorrect functionality of the stomatognathic system.
Today, a new treatment modality has arisen in orthodontics, commonly known as “do it yourself”. This development signals that it is time to start teaching society
about the real power of orthodontics.
Dr Luis Carrière
Specialist in orthodontics and dentofacial orthopaedics

ortho
1 2018

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| content
editorial
The power of orthodontics

03

Dr Luis Carrière

case series
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06

Prof. Carlo Fornaini & Prof. Caroline Bertrand
page 06

case report
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10

Dr Irineu Gregnanin Pedron

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Dr Ana Maria Cantor

research

page 20

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20

Dr Raffaele Spena

technique
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30

Dr Gary Brigham
page 30

industry report
Indirect bonding: .SQS^KV ^OMRXS[_O `] MYX`OX^SYXKV WO^RYN

38

Drs Arturo Fortini, Alvise Caburlotto, Elisabetta Carli, Giulia Fortini
& Francesca Scilla Smith

Hybrid +VSQXO\ >RO\KZc

42

Dr Wajeeh Khan

interview
Cover image courtesy of Ortho Caps GmbH
www.orthocaps.com
1/18

issn 1868-3207 • Vol. 3 • Issue 1/2018

ortho

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Interview with Dr Christian Coachman

manufacturer news

48

international magazine of orthodontics

meetings
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50

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52

technique
Accelerated treatment modalities
in clear aligner treatment

about the publisher

industry report
Indirect bonding: Digital technique
vs conventional method

industry report
Hybrid Aligner Therapy

04

ortho
1 2018

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53

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| case series

In-ofﬁce welding by Nd:YAG laser
Prof. Carlo Fornaini & Prof. Caroline Bertrand, France

Introduction
Just after the introduction of the ﬁrst laser by Maiman
in 1960,1 there was a very fast evolution of this new technology, characterised by constant progression in techniques and applications, increasing the possibility to have
smaller and cheaper devices and introducing ever-new
wavelengths. Laser welding was ﬁrst introduced in the
jewellery industry during the 1970s and soon after successfully used by dental technicians as well.2 The ﬁrst
lasers used were the carbon dioxide and Nd:YAG lasers,
but the market was rapidly conquered by the second,
owing to the results that could be obtained with it.3, 4
Laser welding offers a great number of advantages
compared with traditional welding. Firstly, the laser
device saves time in the commercial laboratory because
all welding is done directly on the master cast. Inaccuracies in assembly caused by transfers from the
master cast along with investment are reduced.5 The
heat source is a concentrated light beam of high power,
which can minimise distortion problems in metals.6 By
using laser technology, it is possible to weld very close
to acrylic resin or ceramic parts with no physical (cracking) or colour damage.7 This means it is possible to save
time and money during the restoration of broken prostheses or orthodontic appliances, because it is not necessary to remake the non-metallic parts. This welding
technique may be used on every kind of metal, but its
property of being very active on titanium makes it particularly advisable for prostheses supported by endosseous implants.8
Many laboratory tests have demonstrated that laserwelded joints have a high reproducible strength for all
metals, consistent with that of the substrate alloy.9 All
these advantages led to this method being extensively
used in dental technicians’ laboratories and stimulated
companies to put on the market increasingly upgraded
appliances. Some aspects, such as large dimensions,
high costs and delivery systems, today still characterise
those machines that use ﬁxed lenses, strictly limiting their
use to dental technicians’ laboratories.
The aim of this study is to show, through the description of a series of clinical cases, the utilisation of a laser
device normally used for surgery in the dental ofﬁce to
weld orthodontic appliances and to demonstrate the
advantages of this technique. The appliance used, the
Fidelis Plus III (Fotona), is a combination of two dif-

06

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ferent laser wavelengths, the Er:YAG (Ѝ = 2,940 nm)
and Nd:YAG (Ѝ = 1,064 nm). The ﬁrst allows the dentist to treat hard tissue (enamel, dentine and bone) with
a mechanism that, utilising the afﬁnity of this laser for
water and hydroxyapatite, induces the explosion of
intracellular water molecules and so causes the ablation of the tissue.10 Its utilisation may be extended also
to dermatology, where it can be employed in the treatment of keloid scars and wrinkles with resurfacing, in
addition to the elimination, by vaporisation, of lesions
such as condyloma, naevi, warts and mollusca contagiosa.11 The Nd:YAG laser allows the dentist to perform
surgery with complete haemostasis, utilising the afﬁnity
of this wavelength for haemoglobin and thus avoiding
the use of sutures.12 The delivery system for this laser
is provided by optic ﬁbres of different sizes, chosen
according to the kind of application needed, ranging
from 200 μm (endodontics) to 900 μm (whitening).
In addition to a pulse duration of microseconds, which
is necessary during dental interventions, the peculiarity
of the Fidelis Plus III appliance is the possibility of pulse
durations of milliseconds (15 or 25), which can be utilised
in phlebology, in the treatment of lesions of vascular
origin, owing to the afﬁnity of this wavelength for haemoglobin.13
In our previous work,14 we demonstrated, by in vitro
tests on different metal samples, the good quality and
high resistance of a joint welded by this device, while in
this paper we demonstrate the clinical application of this
technique.

Material and methods
The laser device used was, as already stated, the
Fidelis Plus III, with a 900 μm ﬁbre and a 2 mm spot
handpiece (R32, Fotona), normally utilised in dermatology, or in some cases a prototype provided by Fotona
itself. The parameters that we normally use for welding are:
– Wavelength:
1,064 nm
– Energy:
9.9 J
– Frequency:
1 Hz
– Spot diameter:
1 mm
– Pulse duration: 15 m/s
– Fluence:
1,260 J/cm2
– Working distance: 8 mm

[7] => ortho_1_2018.indb

case series

Fig. 1

|

Fig. 2

Fig. 1: The damaged appliance removed from the mouth. Fig. 2: The repaired appliance.

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Fig. 3: The Schwartz appliance with a broken Adam’s hook. Fig. 4: Laser welding process without ﬁller metal. Fig. 5: The hook repaired without damaging the
nearby acrylic part. Fig. 6: The appliance replaced into the mouth.

Clinical cases

ance, we decided to weld it directly in the ofﬁce with the
Fidelis laser.

Case 1
A 9-year-old female patient in orthodontic treatment
in our ofﬁce came in urgently owing to damage to the
rapid palatal expander applied to her maxillary molars.
The clinical examination revealed that the brace had been
damaged close to the connection with the arm (Fig. 1).
The patient had just ﬁnished one stage of the expansion,
and since it was very risky to leave her without an appli-

The expander was prepared with the conventional procedure required before laser welding (sandblasted with
alumina powders of 50 μm in diameter using the Miniblaster, Deldent; cleaned with acetone and both parts
dried). The appliance was directly welded in the ofﬁce
using CoCr-Schweißdraht welding wire (DENTAURUM).
After a few minutes only, the appliance was ready to be
recemented into the patient’s mouth (Fig. 2).

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07

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| case series

Fig. 7

Fig. 8

Fig. 7: The Frankel orthodontic appliance with a fractured wire. Fig. 8: The orthodontic appliance repaired.

Fig. 9

Fig. 10

Fig. 11

Fig. 9: The Delaire appliance with a broken wire arm. Fig. 10: Laser welding of the appliance. Fig. 11: The appliance repaired.

Case 2
An 8-year-old male patient in treatment in our ofﬁce
with a Schwartz removable orthodontic appliance came
to us for periodic checking of the appliance, and we
saw that one of the Adam’s hooks had broken (Fig. 3).
We welded it without ﬁller metal (Fig. 4), and the plastic
shield, although very close to the welding zone, was not
damaged or modiﬁed (Fig. 5). We were able to reseat the
repaired appliance in the patient’s mouth after only some
minutes (Fig. 6).
Case 3
An 8-year-old male patient in treatment in our ofﬁce
with a Frankel removable orthodontic appliance came to
us for periodic checking of the appliance, and we saw that
one of the wires had broken (Fig. 7). We welded it without
metal ﬁller (Fig. 8), and the plastic shield, although very
close to the welding zone, was not damaged or modiﬁed. We were able to reseat the repaired appliance in the
patient’s mouth after only some minutes.
Case 4
A 14-year-old male patient came to our ofﬁce with the
lingual wire of his appliance broken. The appliance was

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an orthodontic appliance called Delaire consisting of two
wires, one vestibular and one lingual, connected to two
braces on ﬁrst maxillary molars (Fig. 9). Owing to the
presence of a sizable restoration on the ﬁrst maxillary
right molar, we decided not to remove the appliance and
to perform an intra-oral laser welding. A previously made
screen in silicone was used to protect the soft tissue,
and the appliance was welded without ﬁller metal; the
entire operation lasted 4 minutes; the welding was done
in 75 s (Fig. 10). After a few minutes, without having to
send it to the dental laboratory and with no discomfort to
the patient, the appliance could be repaired (Fig. 11). The
follow-up was done monthly for six months and showed
that the appliance was active and strength-proof.
Case 5
A 14-year-old female patient, in orthodontic treatment
with a Veltri ﬁxed appliance to open the space in the upper
arch in order to insert the second premolar, came to us
for a normal check of the appliance, and it was observed
that an arm had broken near the brace of the ﬁrst premolar (Fig. 12). The removal of the appliance in order to
send it to the laboratory was deemed as having too many
risks, since the treatment was still in the activation phase.
Therefore, it was decided to perform an intra-oral laser
welding. In order to protect the soft tissue, a silicone ﬁlm

[9] => ortho_1_2018.indb

case series

Fig. 12

Fig. 13

Fig. 14

Fig. 15

Fig. 12: The Veltri appliance with a broken arm. Fig. 13: Intra-oral laser welding. Fig. 14: The wire of the appliance repaired. Fig. 15: The appliance reactivated
after welding of the wire.

was employed (Fig. 13). The procedure was performed
without ﬁller metal and took 2 minutes, and the irradiation
time was 20 s (Fig. 14). After the reparation, the therapy
was continued, turning the screw until the required space
was achieved (Fig. 15).

ously, opens a new chapter in laser dentistry, bringing
new possibilities we intend to analyse and test in further research.

Conclusion
The ability to weld broken orthodontic appliances
directly in the ofﬁce represents for the dentist a new
prospect, allowing the restoration of appliances
extremely quickly without additional costs (the welding appliance is the same used for dental therapies).
Being able to maintain the integrity of plastic, acrylic
and ceramic parts close to the welding zone and the
ability to make the reparation while the patient is sitting
in the chair and in one visit only are, in our opinion, the
great advantages in terms of costs, marketing, patient
satisfaction and efﬁciency of the ofﬁce. Moreover, as
shown in the clinical cases presented, the welding process may also be performed intra-orally without risks
and discomfort to the patient. The period of learning
for dentists is very short, owing to the simple and fast
procedure, because the parameters are standard and
it is not necessary to change or adapt them to different clinical situations. We think that this technique represents a valid aid in our daily practice and, simultane-

about
Prof. Carlo Fornaini
is researcher in the MICORALIS
Laboratory at the University of Nice
and teacher of the Diplome InterUniversitaire (DIU) in “Oral Laser
Applications” of the Universities of
Nice and Bordeaux. He can be
contacted at carlo@fornainident.it.
Prof. Caroline Bertrand
is the Dean of the Faculty of Dentistry
of the University of Bordeaux and
Director of the Diplome InterUniversitaire (DIU) in “Oral Laser Applications” of the Universities of Nice and
Bordeaux. She can be contacted
at caroline.bertrand@u-bordeaux.fr.

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| case report

Surgical crown lengthening and
botulinum toxin in the management of the orthodontic patient
with gummy smile
Dr Irineu Gregnanin Pedron, Brazil

Introduction
The demand for cosmetic procedures has grown exponentially. Dental procedures, as well as medical ones,
besides working to obtain the principle of health promotion, seek to achieve smile aesthetics, as the smile is a
form of communication and social expression of many
feelings.1–3

with other disorders, such as temporomandibular disorders (hypertrophy of the masseter muscle, bruxism,
clenching) and myofascial pain.3, 6, 9 The purpose of this
article is to report on a case of a patient who presented
with gummy smile and was treated with a combination of
surgical crown lengthening (gingivoplasty) and application of botulinum toxin.

Case report
Facial aesthetic harmony correlates directly with the
smile and this, in turn, is formed by the union of three components: teeth, gingivae and lips.1–4 The smile becomes
aesthetically pleasing when these elements are disposed
in suitable proportion and exposure of the gingival tissue
is limited to 3 mm. When the gingival exposure is greater
than 3 mm, it characterises the unaesthetic condition
called gummy smile, which affects some patients psychologically.1, 3, 5–8
Several therapeutic modalities have been proposed for
the correction of gummy smile, among them gingivectomy or gingivoplasty,1–3, 5, 6, 8 myectomy6, 8 and orthognathic surgery.6, 8, 9 The last two procedures are more
invasive and associated with high morbidity.7 In contrast,
the use of botulinum toxin can be considered a therapeutic alternative to surgery, because it is a more conservative method, more effective, faster and safer than surgical procedures.5, 10
Botulinum toxin is synthesised by the Gram-positive
anaerobic bacterium Clostridium botulinum and inhibits the release of acetylcholine at the neuromuscular
junction, preventing muscle contraction3, 6, 8, 9. There are
seven distinct serotypes of toxins, A, B, C1, D, E, F and
G. However, the subtype A is the most frequently used
clinically and the most powerful.3, 6
Botulinum toxin has been shown to be effective in the
treatment of gummy smile in patients with hyperfunction
of the muscles involved in smiling, as well as in patients

10

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A 27-year-old African-descendant female patient
attended the clinic with the complaint of gummy smile
(Fig. 1). Clinically, the patient had an anatomical discrepancy between the length of the anterior teeth and evident gingival exposure greater than 3 mm, characterising gummy smile (Fig. 2a). Chu’s Proportion Gauge
(Hu-Friedy, Chicago, US) was used to measure the length
of the teeth (Fig. 2b).
Surgical crown lengthening (gingivoplasty) was proposed and later, after the presentation of the results,
the application of botulinum toxin for the correction of
gummy smile. However, the patient was informed about
the recurrence of gingival smile six months after application, because of its temporary result. Under local inﬁltrative anaesthesia, bleeding points were determined
with the aid of a millimetred probe and the union of these
points was performed with electrocautery.2 The length of
the teeth was increased, characterising the dental zenith.
Subsequently, the scraping was performed, resembling
the technique of external bevel gingivectomy, in order to
enhance tissue healing. There was no need for the use of
surgical cement, given that wound healing would occur
by secondary intention. The patient reported no complaints or complications after surgery.
At the subsequent consultation 30 days later, the
orthodontic appliance was removed and satisfactory
tissue repair was observed (Fig. 3), and no changes
or complaints were reported by the patient. However,

[11] => ortho_1_2018.indb

case report

Fig. 1

Fig. 2a

Fig. 3a

Fig. 2b

Fig. 3b

Fig. 1: The patient presented with gummy smile. Figs. 2a & b: Anatomical
discrepancy between the length of the anterior teeth (A). Length of teeth
measured by Chu’s Proportion Gauge (B). Figs. 3a & b: Thirty days post-op:
Satisfactory tissue repair (A); increased length of teeth measured by Chu’s
Proportion Gauge (B). Fig. 4: Persistence of complaint of gummy smile.
Fig. 5: The patient presented with a uniform dehiscence of the upper lip ten
days after the application of botulinum toxin.

Fig. 4

Fig. 5

the persistence of the complaint of gummy smile was
reported by the patient (Fig. 4). At the same consultation,
botulinum toxin was applied. Prior to application of the
botulinum toxin, the surface of the skin was disinfected
with 70% ethyl alcohol and the oils from the area were
removed, in order to avoid local infection. The points of
application were marked beside each nostril. Then, local
anaesthetic (EMLA, AstraZeneca) was applied with the
aim of promoting comfort during the procedure. Botulinum toxin A (BOTOX 200, Allergan) was diluted in 2 ml of
saline, according to the manufacturer’s instructions, and
two units injected into the predetermined sites, lateral to
each nostril. After application, the patient was advised
not to bend her head forwards for the ﬁrst 4 hours and
not to engage in physical activity for the ﬁrst 24 hours
after the procedure.
After ten days, the patient was examined. She presented with a uniform dehiscence of the upper lip (Fig. 5).
No side-effects or complaints were reported.

Discussion
Gummy smile is characterised by the exposure of more
than 3 mm of gingival tissue during smiling,1, 3, 5, 7 and
it is often seen in women.10 The predominance among
women can be explained by the fact that men present
with a lower smile line.4, 5 Several aetiologies for gummy
smile have been suggested, including vertical maxillary

excess,4–6, 8, 9 delayed passive eruption,4, 6, 7, 9 hyperfunction of the muscles involved in smiling6, 7, 9 and reduced
length of the clinical crown of the teeth.1, 2, 7 These can
occur separately or together, and determine the type of
treatment to be used.
In gummy smile caused by overactive muscles, botulinum toxin is indicated. It is the treatment of choice
for ease and safety of application, and its rapid effect,
besides being a more conservative approach when compared with surgical procedures (myectomy or Le Fort I
osteotomy).3–11 The clinical effects appear within two to
ten days after the injection, and the most visible effect
occurs 14 days after the injection.3, 5 This effect lasts
about three to six months.3, 5, 6, 9
The action of smiling is determined by several facial
muscles, such as the elevator of the upper lip, the elevator of the upper lip and wing of the nose, the zygomaticus major and minor muscles, the muscle of the angle
of the mouth, and the orbicularis oris and risorius muscles.3–6, 8–10 Among them, the ﬁrst three have a greater
inﬂuence and determine the amount of lip elevation and,
therefore, should be the muscles targeted by the injection
of botulinum toxin. The ﬁbres of these muscles converge
at the same area, forming a triangle, and it is here that the
three muscles can be targeted with a single injection. The
injected toxin can spread over an area of 10–30 mm and
this is its effective extent.3–5 The proposed site of injection

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[12] => ortho_1_2018.indb

| case report

is lateral to the wing of the nose.3, 4, 8–10 After being injected
into the predetermined locations, the toxin decreases the
contraction of the muscles responsible for the elevation
of the upper lip, and this reduces gingival exposure.3–11
Each muscle involved in the elevation of the upper lip
has a function during the action of smiling. The points of
the injections are determined by the contraction of speciﬁc muscle groups that results in different areas of gingival display. Several classiﬁcations have been proposed
for gummy smile: anterior, posterior, mixed and asymmetric, depending on the muscle groups involved.4, 10
The anterior gummy smile should be treated with the
conventional technique, with the applications lateral to
the wing of the nose. In patients with posterior gummy
smile, the application of the toxin must involve the zygomaticus major and minor muscles, with the injection of
the toxin at two different points: the point of greatest contraction of nasolabial folds during the action of smiling
and the second point 2 cm lateral to the ﬁrst, at the level
of the ala-tragal line. In the case of patients who have
mixed gummy smile, the application of the toxin should
be performed at all the points mentioned above. However, the dose should be reduced to 50% at the point lateral to the wing of the nose.5 In cases of labial asymmetry, which occurs owing to differences in muscle activity,4
patients receive injections of different doses on either
side of the face.5, 10

The dentist should be attentive to dosage, precision of
technique and location of the injection sites.3, 5, 6, 9, 11 In
this case, no complaints or changes arising from the
application were reported. Contra-indications to the use
of botulinum toxin are pregnancy, lactation, hypersensitivity(allergy) to botulinum toxin, lactose and albumin,
muscle and neurodegenerative diseases (myasthenia
gravis and Charcot-Marie-Tooth disease), and concurrent use of aminoglycoside antibiotic, which enhances
the action of the toxin.3, 9
In this case, the result was satisfactory regarding the
harmony of the smile of the patient by the combination of
treatments, resective gingival surgery and application of
botulinum toxin A. The use of isolated treatments would
not have achieved the excellence of the results obtained.
Initially, the creation of the new dental zenith during the
course of resective gingival surgery promoted the new
dental architecture, favouring gingival-dental-facial harmony for the patient. Subsequently, the application of
botulinum toxin A softened the gummy smile, by the uniform dehiscence of the upper lip, promoting smoothness of the facial lines of the smile, as can be seen in
the nasolabial folds adjacent to the nostrils by comparing Figures 1 and 5.

Conclusion

Botulinum toxin A is a hydrophilic powder, stored under
vacuum, that is sterile and stable.3, 6, 8 The reconstitution occurs with the smooth injection of the diluent (0.9%
sodium chloride) into the bottle. The solution should be
stored at 2–8 °C and used within 4–8 hours in order to
ensure its effectiveness.3, 9

In summary, the application of botulinum toxin is an
alternative treatment that is less invasive, faster, safer and
more effective, and it produces harmonious and pleasing results when applied to target muscles, respecting
the appropriate dose and type of smile. Therefore, it is a
useful adjunct in the aesthetic improvement of the smile
and provides better results when combined with resective gingival surgery.

At the beginning of the treatment, extra-oral photographs, including a close-up of the smile, were taken.
Several authors note the importance of recording the
smile before and after the application of the toxin.6, 10, 11

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

about
It has been suggested that the photographing of the
smile should be performed with the muscles individually stimulated with electrical current in order to ensure
that the muscle contraction is controlled, precise and
repeatable, as a spontaneous smile is extremely difﬁcult
to replicate. Patients know that the treatment is carried
out to produce a different smile, so from this perspective,
unconsciously, there is a tendency to smile differently in
photographs after the treatment.11
The injection of botulinum toxin, despite being a simple
and safe procedure, may be associated with some
adverse events, such as pain at the injection site, bruising, infection, oedema, dysphonia, dysphagia, ptosis or
lengthening of the upper lip and asymmetry of the smile.

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Dr Irineu Gregnanin Pedron
is a specialist in periodontics and implantology. He is an independent
researcher at the College of Dentistry
of the University of São Paulo, Brazil,
and Professor of Periodontology and
Multidisciplinary Clinic at the College
of Dentistry of the University Brasil,
São Paulo, Brazil. He teaches botulinum toxin course in Dentistry at Bottoxindent Institute, São
Paulo, Brazil. He is the author of the book Toxina Botulínica:
Aplicações em Odontologia (Editora Ponto, 2016; Portuguese).
Pedron works in a private practice in São Paulo, Brazil. He
can be contacted at igpedron@alumni.usp.br.

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ALMOST INVISIBLE

INVISIBLE: www.lingualsystems.com

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| case report

Non-surgical treatment of
a Class III malocclusion with
missing lateral incisors
Dr Ana Maria Cantor, Spain

Class III malocclusions are classiﬁed into four types of
skeletal and dental relationships with either (1) mandibular protrusion, (2) maxillary retrusion, (3) a combination
of the two or (4) a normal relationship of the jaws.1–3 The
prevalence of Class III malocclusions is estimated to be
1 to 10 %, depending on ethnicity, sex and age. The aetiology may be skeletal or dentoalveolar.4 The incidence
of lateral incisor agenesis in the permanent dentition is
estimated to be between 1.6 and 9.6 %,5, 6 and there is a
correlation between the size of the maxilla and agenesis
of maxillary teeth.6
The two possible therapeutic options for adult patients
with Class III malocclusions are orthognathic surgery
or camouﬂage orthodontics.7 Regardless of the option
chosen, it is important to take into consideration increasing the angle of convexity (ANB) to improve the proﬁle of
the face with a greater increase in the length of the upper
lip.8 It is, however, often difﬁcult to predict the result that
can be offset by labial inclination of the maxillary incisors
and the subsequent negative effect on the patient’s
smile,9 as well as retro-inclination of the mandibular incisors, with deleterious effects on the periodontium.
The combination of Class III malocclusion with missing
maxillary lateral incisors can be challenging to resolve satisfactorily while enhancing the facial proﬁle of the patient
given the constriction of the maxilla. In patients with these
characteristics, a combination of orthognathic surgery
and orthodontics with a bridge or implants is often recommended.10 Given that the patient in the following case
report would not consider orthognathic surgery or opening space orthodontically for the placement of implants,
the alternative recommended was camouﬂage orthodontic treatment. The case report is intended to illustrate
treatment of a Class III malocclusion exhibiting maxillary
lateral incisor agenesis with the use a simple Class III
functional appliance for anterior-posterior correction, followed by ﬁxed self-ligating appliance therapy.

Diagnosis and treatment plan
A 30-year-old female patient presented with a concave
proﬁle and maxillary hypoplasia with a short upper lip

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and lower retracted labial protrusion, an obtuse nasolabial angle, and skeletal Class III maxillary retrusion and
mandibular protrusion. Dentally, the patient exhibited a
Class III malocclusion with marked crowding, an anterior
crossbite, a 1 mm midline deviation, a moderate curve of
Spee and agenesis of the maxillary lateral incisors that
the panoramic radiograph conﬁrmed (Figs. 1a–j; Tab. 1).
The treatment goals were to improve the patient’s facial
aesthetics, correct the Class III malocclusion exclusively
with orthodontics, reduce the concavity of her proﬁle and
create greater fullness of the upper lip, correct the anterior crossbite, distalise the mandibular posterior segment, protract the maxilla and close the spaces from
the congenitally missing lateral incisors, reconstructing
the canines as lateral incisors and the ﬁrst premolars as
canines. Since the patient rejected the more invasive
options recommended and opted for camouﬂage orthodontics, she was cautioned that a satisfactory result
depended on her strict compliance with the treatment
protocols, speciﬁcally the use of elastics.

Wire sequence
Treatment followed the Carriere System (Henry Schein
Orthodontics) archwire sequence, except in this case
the ﬁrst wire was a 0.016 in. dimension wire rather than a
0.014 in. wire. The archwires were all thermally activated
wires, with lower transformation temperatures chosen as
archwire sizes increased to limit force on the periodontium:
– 0.016 in. Cu Nitanium (27 °C)
– 0.014 × 0.025 in. Cu Nitanium (27 °C)
– 0.017 × 0.025 in. Cu Nitanium (35 °C)
– 0.019 × 0.025 in. Cu Nitanium (35 °C).

Treatment progress
Treatment commenced with the simultaneous use of
a Carriere Motion 3D Class III Appliance (Henry Schein
Orthodontics) for sagittal correction and Carriere SLX
(Henry Schein Orthodontics) 0.022 in. MBT prescription
pre-adjusted, passive self-ligating brackets bonded with
0.016 in. Cu Nitanium archwires engaged in the upper
arch for anchorage. The Motion 3D Class III appliance

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case report

Fig. 1a

Fig. 1d

Fig. 1b

Fig. 1c

Fig. 1e

Fig. 1g

Fig. 1i

|

Fig. 1f

Fig. 1h

Fig. 1j

Figs. 1a–j: Patient with a Class III malocclusion and agenesis of the maxillary lateral incisors before treatment.

was bonded directly to the mandibular canines and ﬁrst
molars with 6 oz, 0.25 in. intra-oral elastics engaged for
Class III traction to maxillary second molar tubes. Upper
arch levelling and alignment was performed with 0.016 in.
Cu Nitanium archwire, and bilateral stops placed mesially
to the bonded ﬁrst molar buccal tubes to assist with protraction of the upper arch.

Proper patient compliance achieved correct intercuspation in four months; the negative overjet had corrected to an end-on position in ﬁve months (Figs. 2a–c).
At that point, the Motion appliance was debonded and
Carriere SLX 0.022 in. MBT prescription pre-adjusted,
passive self-ligating brackets were bonded in the lower
arch (Figs. 3a–c).

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| case report
Tab. 1: Pre-treatment cephalometric data.

Treatment results

Discussion

After 16 months, treatment concluded with the patient
showing a signiﬁcant proﬁle improvement, a correction of
the maxillary hypoplasia, anterior crossbite and Class III
malocclusion with greater upper lip fullness, a balanced
smile line, adequate gingival margins, levelling, and suitable overjet and overbite. By replacing the congenitally
missing lateral incisors with reconstructed canines and
positioning reconstructed ﬁrst premolars as canines,
good occlusion was achieved (Figs. 4a–c).

Many Class III patients elect not to undergo invasive treatment that involves surgery, extractions and/or
implants, especially if treatment affects maxillary anterior
teeth considered critical to overall smile aesthetics. When
such aesthetic problems are presented, it is important
that orthodontists have adequate training in and experience and awareness of facial aesthetics to be able to
offer more conservative solutions because such issues,
if unresolved satisfactorily, can detrimentally affect the
patients’ emotional state and self-esteem.

For the re-anatomisation of the canines and ﬁrst premolars, we performed a laser diode gingivoplasty, then
shaved the cusp tips of the canines and sculptured their
distal and mesial borders with composite resin. Finally,
we shaved and recontoured the palatal cusps of the
ﬁrst premolars to avoid premature contact at functional
occlusion (Figs. 5a–j; Tab. 2).

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The position of the maxillary and mandibular incisors
determines facial harmony and a pleasing smile. Maxillary lateral incisor agenesis makes obtaining good
treatment results a challenge, especially with reduced
maxillary arch length, owing to the lack of these important teeth.

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case report

Fig. 2a

Fig. 3a

Fig. 4a

Fig. 2b

Fig. 3b

Fig. 4b

Fig. 2c

Fig. 3c

Fig. 4c

Figs. 2a–c: After ﬁve months of sagittal treatment, the negative overjet had corrected to an end-on position. Mild extrusion of the mandibular canine can be
observed, which was expected and a positive sign of the effects of the sagittal correction. The result was an anticlockwise rotation of the posterior occlusal
plane, producing signiﬁcant improvement in the prognathic proﬁle. Figs. 3a–c: After bonding the mandibular brackets. Figs. 4a–c: After 14 months of treatment, the case demonstrated a corrected overjet, overbite and intercuspation. The canines occupied the positions of the congenitally missing lateral incisors.

Treatment plans for cases of maxillary hypoplasia
with agenesis of the lateral incisors often call for opening space for implants. The greatest problem with such
plans is that it is impossible to predict when, to what
degree, or in which patients unattractive soft- and/or
hard-tissue changes around implant-supported porcelain crowns, especially noticeable in the maxillary anterior teeth, will occur. Biological and technical complications are frequent and can appear even after only a few
years.12
Space closure with protraction of the maxilla and later
re-anatomisation of the canines to replace the congenitally missing lateral incisors can be a good alternative.
Handled carefully, this option avoids gingival retraction
that can accompany implant placement or metal showthrough on crowns, bridges and implants that can occur
in some restorations after a period. Clinicians treating
Class III patients with maxillary hypoplasia have traditionally avoided space closure because of the potentially adverse effects on the proﬁle. The combined use of
the Motion 3D Class III Appliance and SLX Brackets for
applicable cases biomechanically eliminates these side-

effects by optimising the relationship between the maxilla and the mandible, both occlusally and aesthetically,11
for better results than simply neutralising the potentially
adverse effects of opening space for implants.
Camouﬂage orthodontic treatment can result in protrusion8 of the maxillary incisors (giving an appearance
of a short upper lip), as well as retro-inclination of the
mandibular incisors, with deleterious effects on the periodontium. The actions of the Carriere Motion 3D Class III
Appliance is distalisation of the mandibular segments
from molar to canine as a unit, with intrusion of the mandibular molars, extrusion of the mandibular canines and
retraction of the mandibular incisors, the result of which is
an anticlockwise rotation of the posterior occlusal plane,
producing a signiﬁcant improvement in the prognathic
proﬁle.11 In Class III cases, choosing brackets rather than
an aligner for anchorage and bonding them simultaneously with the functional appliance produces distalisation of the mandibular posterior segment while achieving torque control of the maxillary incisors11 and space
closure, yet with a protractor effect on the maxilla that
develops upper lip fullness.

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| case report

Fig. 5a

Fig. 5d

Fig. 5b

Fig. 5c

Fig. 5e

Fig. 5g

Fig. 5f

Fig. 5h

Fig. 5i

Fig. 5j

Figs. 5a–j: Final photographs and radiographs of the patient after 16 months of treatment.

Conclusion
Treatment with the Carriere Motion 3D Class III Appliance is efﬁcient for the correction of adult Class III malocclusions, producing satisfactory results both aesthetically and functionally. The Carriere Motion 3D Class III
Appliance used in combination with Carriere SLX Selfligating Brackets is a biomechanically efﬁcient means of
addressing cases with maxillary hypoplasia. Compared
with alternatives, such as a combination of surgery and

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conventional orthodontics for opening space for implants
or bridges, these appliances can signiﬁcantly reduce
treatment time for treatment of Class III patients. In cases
of agenesis of the maxillary lateral incisors, the approach
represented by this case is an efﬁcient alternative for
closing spaces while balancing the patent’s proﬁle and
correcting the Class III malocclusion.
Editorial note: A list of references is available from the
publisher.

[19] => ortho_1_2018.indb

case report

|

Tab. 2: Post-treatment cephalometric data.

Fig. 6: Superimposition of cephalometric tracings pre- and post-treatment.

contact
Dr Ana Maria Cantor
practises orthodontics at the private
OdontoKids clinic in Malaga
in Spain. She can be contacted at
anamacantor@yahoo.es.
Fig. 6

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Six keys to effectively using
alveolar corticotomy: A different
perspective on surgically
assisted tooth movement
Dr Raffaele Spena, Italy

Introduction
Alveolar decortication (corticotomy) has long been
used with orthodontic treatment in order to accelerate
orthodontic tooth movement (OTM) while reducing the
undesired effects of root resorption, loss of vitality, periodontal problems and relapse of the corrections. The
acceleration of tooth movement should shorten the therapy. However, the scientiﬁc and clinical assumptions of
the early days were totally different from the more recent
ones: we moved from a pure mechanical approach to a
biological and physiological one.
In 1983, Suya1 proposed a great improvement of the
surgical approach described in 1959 by Kole2 modifying
the horizontal osteotomy in a corticotomy, avoiding the
alveolar crest in the vertical cuts and eliminating the
luxation of the blocks. He proposed this “corticotomyfacilitated orthodontics” to treat adult patients, ankylosed teeth and crowded malocclusions to avoid premolar extractions. Like Kole, Suya believed he was creating
bony blocks and suggested accomplishing most of the
movements in the ﬁrst three to four months of treatment
before the fusion of the blocks (healing of the bone).
The concept of corticotomy-assisted OTM drastically
changed in 2001 after the publication of Wilcko et al.3 In
this key case report, two adult patients received a selective corticotomy, along with alloplastic resorbable grafts,
to increase the bone level and avoid the risk of recessions. An accurate evaluation with CT scans before and
after treatment, and histological sections in one case,
allowed the authors to formulate a new hypothesis about
what really happens at the bone level after corticotomy.
No movement of tooth–bone blocks, but a transient
reduction of mineralisation of the alveolar bone and modiﬁcations similar to those described by Frost4–7 during the
healing of fractured bones and named “regional acceleratory phenomenon” (RAP) most likely occur. The surgeryorthodontic protocol proposed by Wilcko et al.3 has been
subsequently patented as Periodontally Accelerated
Osteogenic Orthodontics (PAOO). The claims of PAOO are

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(a) accelerated tooth movement with reduction of the total
treatment time; (b) osteogenic modiﬁcations with transportation of the bony matrix, and ﬁnal improvement of
hard- and soft-tissue support of the teeth treated orthodontically; (c) increase of the short- and long-term stability of the orthodontic treatment. So far, scientiﬁc evidence
has been given only on the acceleration of tooth movement that is transient, and lasts as long as there is a RAP
modiﬁcation in the alveolar bone surrounding the teeth.
After more than one and a half decades of clinical
experience with alveolar corticotomy, in light of the current literature published on this topic, six rules have been
established that should be taken into account when considering using alveolar corticotomy in a complex orthodontic case. These keys are the best way to ensure effectiveness and reduce the risk of producing no positive
effect or, worse, causing damage. The six keys are as
follows:
1. Alveolar corticotomy is to facilitate OTM.
2. Alveolar corticotomy has limited effect in time.
3. Alveolar corticotomy has limited effect in space.
4. A proper surgical procedure must be followed.
5. Proper orthodontic management after corticotomy
must be performed.
6. Proper patient selection for corticotomy is essential.
A detailed description of each rule follows.
1. Alveolar corticotomy is to facilitate orthodontic tooth
movement (Periodontally Facilitated Orthodontics)
Speed is a fascinating issue in life. We like to go fast in
cars, motorbikes, boats, airplanes and so forth. Speed
in orthodontics is a different matter. It is one of the main
objectives of modern orthodontics to reduce treatment
time, but we must recognise that a great number of variables may affect it.8–11
The initial difﬁculty of the malocclusion and tooth malposition, the age of the patient, the variability of the individual response to the treatment, the quality of the end

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research

result, and the patient’s compliance are just a few of the
variables that should be considered. Numerous case
reports have been published showing how treatment
time can be reduced when patients are treated with corticotomy. Case reports, however, have limited scientiﬁc
validity.
The predictability and quantiﬁcation of treatment time
reduction are still not scientiﬁcally possible. The additional expenses and morbidity associated with the use of
alveolar corticotomy should always be carefully evaluated
to determine whether they are worth the saving of few
months. A shorter orthodontic treatment is desirable, but
certainly not at the expense of a high-quality end result.
Regarding OTM, numerous studies have shown that its
speed is inﬂuenced by bone turnover and the individual
response to mechanical forces and it is not related to the
level of the forces.12–15 Clinical experience conﬁrms this:
there are slow movers and fast movers, but we are still far
from recognising them. In addition to this variability, there
is the temporary effect of alveolar corticotomy, which we
will discuss under the third key. A faster treatment may be
a secondary advantage and may be obtained in a substantial way only in those “simple” orthodontic cases that
require a naturally short treatment.
In conclusion, alveolar decortication should not be
combined with orthodontic treatment with the only objective of accelerating OTM and reducing treatment time: the
risk of not obtaining either as desired may be high.
Despite this scientiﬁc evidence against its major claims,
alveolar corticotomy has its place in orthodontic therapy.
Let us consider the surgical insult and the associated
RAP reaction produced at a biomechanical level: the
increased metabolism, the transient reduced regional
density (osteopenia) created by the increased osteoclastic activity, the reduced undermining resorption and hyalinisation (we still do not know exactly what happens in
humans) facilitate OTM. The decorticated tooth is less
resistant to orthodontic forces and will be easier to move
and will require less anchorage.
Spena et al. in two studies conducted on a total of
12 adult patients with Class II malocclusions treated with
distalisation of the maxillary molars showed how maxillary molars could be bodily distalised with simple buccal
mechanics and no anterior anchorage.16, 17 Corticotomy
was performed only on the teeth to be moved, thus
reducing the anchorage needs and their resistance to
distal forces.
The term “Periodontally Facilitated Orthodontics”,
instead of “Periodontally Accelerated Osteogenic Orthodontics”, is used to describe a procedure that has the pri-

mary goal of simplifying, enhancing and improving OTMs
that are difﬁcult or risky, from a biomechanical and biological point of view. The surgical procedure and the associated orthodontic treatment and biomechanics depend
on the initial problems and the goals of every single speciﬁc treatment. This is in agreement with Oliveira et al.:
corticotomies should be used to “…facilitate the implementation of mechanically challenging orthodontic
movements and enhance the correction of moderate to
severe skeletal malocclusions”.18
2. Alveolar corticotomy has limited effect in time
Since the early studies of Frost on the biology of fracture healing, it is known that the altered metabolism
of bone after a traumatic (or surgical) event has limited duration: it is the natural search for equilibrium or
homeostasis.
The burst of hard- and soft-tissue remodelling starts
a few days after the insult, peaks at the ﬁrst or second
month, and returns to a normal pace after a maximum
of four to six months. This RAP reaction, when applied
to the alveolar bone, causes an accelerated/facilitated
movement of the teeth subjected to applied orthodontic
forces. The effect lasts for as long as there is this reaction, so for a limited part of an orthodontic therapy. This
has been conﬁrmed by experimental studies on animals
and by clinical studies on patients.19 Clinically, this temporary phenomenon leads to the need to perform the
alveolar corticotomy when the RAP is necessary. Timing
is fundamental.
Alveolar corticotomy may be repeated during the
treatment with the objective of prolonging the effect.20
The effective beneﬁt, cost and risks must be taken into
account. Sanjideh et al. in a split-mouth study on foxhounds found that a second corticotomy performed after
28 days in the mandible produced a higher rate of tooth
movement and a greater total tooth movement.21 However, they concluded that proper timing for a second corticotomy needed to be better determined.
Wilcko,22–24 Dibart25 and Murphy26, 27 claimed that continuously activated orthodontic forces applied after
decortication may maintain a constant mechanical stimulation, and allow a prolonged osteopenic state during
which teeth can be moved rapidly.
In order to achieve this effect, they recommended
seeing patients frequently (every two weeks) and continuing the activation of the applied orthodontic forces. If
not, remineralisation would complete the healing process
and bring the bone metabolism to a normal level. It must
be said that these claims have never been demonstrated
either clinically or histologically.

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Fig. 1

Fig. 2

Fig. 3

Fig. 4

3. Alveolar corticotomy has limited effect in space

impede an extended decortication, the cuts may be limited in the direction of the OTM. These biomechanical
needs determine the type of procedure in both the openﬂap and the ﬂapless surgeries.

The effects of alveolar corticotomy are localised to
the area immediately adjacent to the site of injury.28 This
ﬁnding is of outmost importance. Different surgeries
may affect differently the resulting OTM. Glenn et al.29
and Tuncay and Killiany,30 in two experimental studies
on animals published before the new trend on corticotomy, found that ﬁberotomy (a corticotomy limited to
the crestal side of the alveolar bone) affected the rate of
OTM and shifted the centre of rotation toward the apex
of the roots, thus modifying the biomechanical behaviour
of the teeth under the orthodontic forces. If the surgical
insult is applied to a limited area of the alveolar bone (i.e.
middle third and only buccal surface; Fig. 1), the RAP
reaction will not be extended to the entire root area. The
modiﬁcations at the bone level will be limited at the area
of the decortication, and control of the apical and lingual
sides will not be inﬂuenced as desired.
As a general rule, if a mesiodistal bodily movement or
better control of the apical area are the biomechanical
needs of the OTM to be achieved and enhanced (i.e. intrusion/extrusion), the decortication needs to be extended
to the entire alveolar bone surrounding the roots of the
teeth, buccally and lingually (Fig. 2); if the movement is
less complex or anatomical limitations of the surgical site

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4. A proper surgical procedure must be followed
Several surgical protocols for performing alveolar corticotomy have been proposed. Most of them have been
tried in the last 15 years on several patients. These surgeries may be divided into two groups: the open-ﬂap and
the ﬂapless corticotomies (Tab. 1).
The original corticotomies were performed after raising a ﬂap. This type of surgery is still preferred when an
extended or critical area of decortication has to be managed and when an extended grafting is planned.
The ﬂap can be designed according to the periodontal
characteristics of the site and has to be full thickness in
the area of decortication and split thickness below this
area to ensure a good blood supply. Interproximal and
subapical cuts of 1–2 mm in the cortical bone (Figs. 3 & 4)
are performed together with a light scraping of the external cortex in between the cuts. This extended surgical
insult will produce a wide RAP reaction and prepare a
bleeding bed for any grafting material eventually placed

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research

Tab. 1: Surgical protocols for performing alveolar corticotomy.

Open-ﬂap corticotomies

Flapless corticotomies

· Periodontally Accelerated Osteogenic Orthodontics

· Fiberotomy

· Segmental corticotomy

· Corticision

· Any corticotomy performed during an open-ﬂap surgery

· Piezocision
· Micro-osteoperforations

Fig. 5

in association with the decortication. Piezo-surgical
calibrated micro-saws are preferred to rotating surgical
burs because of their selective, safer, micrometric and
more precise cuts; better irrigation/cooling effect from
cavitation; better comfort for the surgeon; and better
healing for the patient. The open-ﬂap corticotomy procedure is routinely used during orthognathic surgery,
when exposing impacted teeth, to treat transverse maxillary deﬁciencies and periodontally involved cases.
Flapless surgery has been proposed as an alternative
way of performing a corticotomy. Corticision31 and Piezocision32 have been an attempt to reduce the invasiveness of the decortication and the possible periodontal
damage and postoperative discomfort with raising a ﬂap.
Even if attractive, they seem to have surgical and biomechanical limitations.
The surgical limitations include risks when performed in crowded arches, limited visibility when producing the cuts, limitation of the cuts to the interproximal areas and to the middle third of the
roots, difﬁcult control of the grafting in the apicocoronal direction and need for optimal extension of the
attached gingiva in the area of decortication. The biomechanical limitations are strictly related to the fact that cor-

Fig. 6

ticotomy is performed only on the buccal side and middle
third of the roots.
They are deﬁnitely not minimally invasive surgeries as
claimed and are quite expensive for the patient, since
only a well-trained periodontist/oral surgeon can perform
them and they often require complex planning with digitally designed 3-D surgical guides.33
The Micro-Osteo-Perforations (MOPs) described by
Alikhani et al.34 and Teixeira et al.35 are an effective and minimally invasive way of producing insult to the cortical alveolar bone. These MOPs may be created with manual instruments (Excellerator, Propel Orthodontics) or with dedicated
burs on a reduced-speed electric handpiece (Fig. 5).
MOPs are produced with a penetration in the cortex
of a maximum of 1–2 mm. Instead of conventional local
anaesthesia, a strong anaesthetic gel placed on the
mucosa for three minutes is sufﬁcient to control the
patient’s pain and discomfort. It is advisable to produce
two to three MOPs in each interproximal area of the teeth
and both buccally and lingually (Fig. 6), to ensure that the
metabolic changes are extended around the entire radicular alveolar bone. Manual MOP is usually created in the
frontal areas, whereas drilled MOP is usually performed
in the posterior and lingual areas (Figs. 7–9). The pro-

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Fig. 7

Fig. 8

cedure and the precautions are similar to the insertion
of mini-screws. Orthodontists can easily create MOPs at
the chairside, and the cost is a great deal more affordable for the patient. Finally, they can easily be repeated
during treatment if additional bone stimulation is needed.
No packing and no sutures are necessary after MOP. The
limit is that no grafting can accompany MOP.
Whenever possible and desirable, grafting may
accompany alveolar corticotomy. The grafting is usually planned before surgery, based upon initial clinical
and radiographic evaluation, the desired OTM, and the
short- and long-term periodontal considerations. In situations of thin bone and a thin gingival biotype, with risky
movements like expansion, labial proclination or anteroposterior movements in reduced bone volumes, grafting
may be indicated to reduce/eliminate fenestrations and
dehiscences, produce additional support for the roots,
and improve ﬁnal aesthetics and stability.
Grafting may include hard-tissue, soft-tissue and autologous growth factors. Quality and quantity may be modulated at the surgery depending on the clinical conditions of the surgical site. As a general rule, composite
bone grafts where allogeneic bone (bone from human
cadavers that is freeze-dried to reduce antigenicity and
demineralised to expose the underlying collagen and its
growth factors, like bone morphogenetic protein) with
osteoinductive properties, is mixed with xenogenic bone
(bone usually from bovine animals that provides a physical matrix or scaffold suitable for deposition of new bone
and that prevents its rapid resorption) with osteoconductive properties are preferred (Fig. 10).
Soft-tissue grafts are added to bone graft when a thin
biotype or gingival recession is present. If the area to be
regenerated is small, an autologous connective tissue graft
is the gold standard procedure. Large areas may be managed with allogenic human acellular dermal matrices, that
are available in different sizes and thicknesses (Fig. 11).
Soft-tissue grafts are sutured with resorbable sutures.
Both bone and soft-tissue grafts are coupled with autologous growth factors. With ageing, the number of stem
cells rapidly decreases. These cells are important in

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Fig. 9

case of injury and healing processes. Studies have
shown that growth factors from platelet-concentrated
plasma (platelet-derived growth factor, vascular endothelial growth factor, transforming growth factor beta 1
and 2) may rapidly increase the number of the available stem cells, stimulate their activity, as well as reduce
inﬂammation and pain during the healing processes.36
Platelet-rich ﬁbrin (PRF) 37, 38 and the platelet rich in
growth factors (PRGF) 39, 40 are prepared via two different protocols in which blood centrifugations allow separation of the plasma platelets from the white and red
cells. PRF contains leucocytes and the process for its
preparation produces membranes with a light compression of the centrifuged fraction.
The process for preparing PRGF allows the separation of three fractions with different concentrations of
platelets. They may be mixed with bone grafts (increasing the graft’s viscosity and adherence to the surgical site, thus facilitating its application) and soft-tissue
grafts. Activating and heating the PRGF fraction produces clots/membranes of ﬁbrin that are placed on the
bone grafts, stabilising their position (Fig. 12).
When using grafts along with alveolar corticotomy, a
tension-free ﬂap closure must be achieved at the end of
the surgery, to provide optimal coverage of the decorticated area and the grafted material, and to enhance ﬁnal
soft-tissue healing. Non-resorbable sutures are left for at
least 14–21 days.
5. Proper orthodontic management after corticotomy
must be performed
Orthodontic treatment associated with periodontally
facilitated orthodontics may be carried out with any ﬁxed
or removable appliances. It is the clinician’s choice to
combine periodontally facilitated orthodontic procedures
with ﬁxed, active self-ligating appliances (In-Ovation) with
the new prescription of the CCO System (GAC-Dentsply
Sirona; Fig. 13).41
The management and wire changes are similar to
those of any orthodontic case. No initial heavy force is
necessary. There is no rule regarding timing of the bond-

[25] => ortho_1_2018.indb

research

Fig. 10

Fig. 11

Fig. 12

Fig. 13

Fig. 14a

Fig. 14b

Fig. 15

Fig. 16a

Fig. 16b

ference is that, after the periodontal surgery and until
tooth movement is clearly enhanced, the visits for wire
activations or wire changes are every two weeks instead
of the usual six to eight weeks.
When corticotomy is performed along with aligner
treatment, the frequency of appliance changes is every
three to four days.
Alveolar corticotomy may easily be associated with skeletal anchorage devices. Temporary anchorage devices
are used to increase anchorage, while corticotomies are
used to reduce anchorage.
6. Proper patient selection for corticotomy is essential

Fig. 17

ing: in some cases, appliances are placed a week after
the surgery, while in others (for example, when distalising maxillary molars or repositioning impacted teeth)
several months before corticotomy.
The enhanced tooth movement deriving from the
RAP reaction is obtained when needed. The major dif-

Alveolar corticotomy is not for every patient, and it is
not feasible to use it on a routine basis in clinical practice. The main indication is in clinical cases with complex
OTMs. Open-ﬂap surgery is indicated in impacted teeth,
surgery-ﬁrst procedures with extractions, orthognathic
surgery with major postoperative OTMs, complex space
closures with reduced supporting tissue, and maxillary
expansion in periodontally compromised cases. MOP
is indicated in treatments with aligners, complex OTMs
without periodontal problems and patients with ﬁnancial
limitations.

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| research

Fig. 18a

Fig. 18b

Fig. 18c

Fig. 19a

Fig. 19b

Fig. 19c

Fig. 19d

Fig. 20

Fig. 21a

Fig. 21b

One case treated with open-ﬂap corticotomy and two
cases treated with MOP will be shown to elucidate the
concepts described in this article.
Case 1
A 19-year-old male patient with a Class III dental malocclusion with anterior midline discrepancy wanted to be
treated only with aligners (Figs. 14a & b). Treatment was
carried out with 71 aligners and two MOPs performed
at the second month and at the ﬁfth month of treatment, only on the premolar and molar maxillary dentition
(Fig. 15). Class III elastics were prescribed throughout the
therapy. Treatment was completed in seven months with
acceptable intercuspation in the buccal segments and
correction of the midlines (Figs. 16a & b) and with good
anchorage control in the lower arch (Fig. 17).

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Fig. 21c

Case 2
A 22-year-old female patient with a Class II, Division 1
dental malocclusion with a missing mandibular right ﬁrst
molar and mandibular anterior midline deviated toward
the right presented for treatment (Figs. 18a–c). The treatment plan was to extract the maxillary ﬁrst premolars and
close the mandibular right molar space with minimum
anchorage. MOPs were performed after insertion of the
mandibular working wire (0.019 × 0.025 in., stainless
steel; Figs. 19a–d). Nickel-titanium closed coil springs
were applied right after the decortication (Fig. 20). Treatment was completed with good intercuspation, coincident midlines and all spaces well closed (Figs. 21a–c).
Figures 22a to d show the dental panoramic tomograms
and lateral cephalometric radiographs before and after
treatment.

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research

Fig. 22a

Fig. 22b

Fig. 22c

Fig. 22d

Fig. 23a

Fig. 23b

Case 3
A 30-year-old male patient, after two unsuccessful previous orthodontic treatments, with a Class II malocclusion with an anterior open bite, a unilateral cross bite and
generalised recession on the buccal aspects of maxillary teeth presented for treatment (Figs. 23a & b). The
ideal treatment would have included surgically assisted
maxillary expansion, followed by combined orthodontic–
orthognathic surgery. The patient refused this treatment,
but accepted an alternative treatment with open-ﬂap
corticotomy extended from molar to molar and generous hard- and soft-tissue grafting (Figs. 24a & b). Treatment started a week after the surgery and continued
with visits every two to three weeks. Once arch coordination had been slowly achieved with 0.019 × 0.025 in.
stainless-steel archwires (Figs. 25a & b), followed by

Fig. 24a

Fig. 24b

0.021 × 0.025 in. stainless-steel archwires (Figs. 26a & b
and 27a & b), the anterior open bite spontaneously closed
(Figs. 28a & b). The CBCT images before and after treatment reveal the increased volume of the maxillary alveolar
bone that allowed the successful expansion of the upper
arch, despite the age of the patient and the initial periodontal problems (Figs. 29a & b).

Conclusion
Alveolar corticotomy (or periodontally facilitated orthodontics as we prefer) is an effective procedure in which
alveolar decortication is associated with orthodontic
treatment with the primary goal of enhancing OTM and
reducing anchorage needs. By accelerating the rate of
OTM and reducing the complexity of a clinical case, bone

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| research

Fig. 25a

Fig. 25b

Fig. 26a

Fig. 26b

Fig. 27a

Fig. 27b

Fig. 28a

Fig. 28b

Fig. 29a

Fig. 29b

decortication may reduce treatment time. However, this
effect is considered a side-effect and not the primary
reason for using this periodontal surgery. According to
the patient’s needs, it may be performed with an openﬂap or a ﬂapless procedure and may be associated with
hard- and soft-tissue grafting. Further studies are still
needed to evaluate indications, contra-indications and
risks. The procedures described here will certainly evolve
and improve with the improvement of the materials,
devices and appliances utilised.
Editorial note: A list of references is available from the
publisher.

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contact
Dr Raffaele Spena
Via dei Mille, 13
80121 Napoli
Italy
rspen@tin.it
www.raffaelespenaortodonzia.it

[29] => ortho_1_2018.indb

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| technique

Accelerated treatment modalities
in clear aligner treatment
Dr Gary Brigham, US

Adopting new technologies is critical to any orthodontic practice that aspires to expand and innovate in the
twenty-ﬁrst century. Responding to patients’ evolving
needs is vital to establishing patient satisfaction with treatment and subsequent practice success. Accordingly, the
capacity to offer patients unique treatment beneﬁts that
speciﬁcally address their principal concerns, is perhaps
one of the most important driving forces to incorporating acceleration technologies and adjunctive treatment
modalities into practice. Signiﬁcantly, when these technologies are used in combination with other innovative
treatments, such as clear aligner therapy, the resultant
synergy can potentially result in markedly improved and
timely treatment outcomes. Such is the case, I believe,
with micro-osteoperforation (MOP) for acceleration of
orthodontic treatment, and high-frequency vibration
(HFV) for enhanced clear aligner seating and pain/discomfort reduction.
I have found MOP to be clinically effective in acceleration of treatment and in enhancement of clinical results
for a broad range of malocclusions, including crowding,
space closure, molar uprighting, rotations, intrusions and
extrusions.1–3 A research survey of adult patients has indicated that a majority were interested in any procedures
that could effectively reduce their treatment time.4
My decision to implement MOP in my own treatment
procedures arose from increasing requests from my
patients to reach their orthodontic aesthetic and functional goals, within a time frame that aligned with their
expectations as well as their own estimated capacity for compliance with treatment. Even with Invisalign’s
current seven-day aligner exchange protocol, patients
have expressed interest in further truncating their treatment time, without increasing the discomfort sometimes
associated with tooth movement. MOP has proven to
be instrumental in addressing these patient concerns in
my practice. It can be performed chairside within several
minutes using the Excellerator PT power driver with the
disposable surgical grade Excellerator PT power tips. I
ﬁnd predictability and conﬁdence in knowing this device
is speciﬁcally designed and indicated for performing multiple micro-osteoperforations in a single treatment. The
procedure can be applied in both ﬁxed and removable
orthodontic appliance therapy, but is especially dramatic
in its capacity to impact clear aligner treatment.

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The science underlying MOP is based in orthopaedics
dating back over 100 years. In 1989, Harold Frost coined
the term “Regional Acceleratory Phenomenon” (RAP) to
describe this predictable remodelling response of bone
to iatrogenic stimuli. Its premise suggests that disruption
of the cell membranes of osteocytes, the most ubiquitous
cell in bone, stimulates their secretion of a cascade of
cytokines and chemokines that accelerate the physiological rate of bone remodelling.5–7 As research has demonstrated that the rate of tooth movement is dependent upon
the rate of the physiologic process of bone remodelling,
it is reasonable to surmise that an increase in the rate of
bone remodelling should correlate with an increase in the
rate at which clear aligners can be exchanged.3, 6–8 Use of
the Excellerator PT device to create micro-osteoperforations of the cortical plates of interseptal bone activates a
chemically-based natural immune response, that accelerates bone turnover and subsequent tooth movement
when orthodontic forces are simultaneously applied.5, 6
The procedure conducted under topical, or local
anaesthetic imparts minimal discomfort to the patient.
To further mitigate any potential discomfort, the patient is
instructed to take 1,000 mg of Tylenol one hour prior to
the appointment. In preparation for conducting the MOP,
a topical anaesthetic gel (12.5% lidocaine, 12.5% tetracaine, 3.0% prilocaine and 3.0% phenylephrine) is sparingly applied and is supplemented with local inﬁltration
anaesthesia using Septocaine (4.0% articaine HCL and
epinephrine 1:100,000) in buccal and labial vestibule if
needed. Following MOP, the patient is further directed to
take 500 mg of Tylenol (acetaminophen) every six hours
for the next 24 hours to alleviate any residual discomfort
associated with the procedure. Signiﬁcantly, a majority of
patients have reported that they did not require the use of
any post procedure analgesics.
Case 1: MOP can especially be used effectively in
conjunction with clear aligner therapy. For example, in
Figures 1a and b, a 19-year-old female patient presented
with a vertical Class II skeletal malocclusion four years
post ﬁxed appliance treatment. She demonstrated clinically a retrognathic chin point, an anterior open bite with
inadequate incisal guidance, and dark buccal corridors.
A treatment plan including adjunctive MOP therapy in
conjunction with Invisalign Teen treatment was accepted
by the patient, with the patient caveat that no elastics

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technique

Fig. 1a

Fig. 1b

Fig. 1a: Initial. Fig. 1b: Treatment plan. Fig. 1c: Treatment sites.

would be used and that the treatment would be completed in 12 months. The treatment plan included creating graduated Curves of Spee in both arches by means of
maxillary molar and second bicuspid intrusion and mandibular ﬁrst molar and second bicuspid intrusion, following one of Dayan’s posterior tooth intrusion protocols for
anterior open bites.9 The intrusion mechanics were anticipated to generate a mandibular hinge axis of closure that
would create a forward projection of the chin point to
improve the patient’s proﬁle and establish incisal guidance while respecting the patient’s maxillary incisal display without the use of elastics. The anticipated forward
projection of the mandible offered the secondary beneﬁt
of applying interproximal reduction to the proclined mandibular incisors to create space to upright these teeth to
an improved position, and to increase the overjet through
incisor retraction to accommodate the forward projection
of the mandible. In addition, a broadened arch form was
expected to be created to address the dark buccal corridors without concern for opening the patient’s vertical
further, by virtue of the occlusal coverage afforded by the
aligners as well as the adjunctive treatment. The maxillary incisors were extruded less than 1 mm to establish
an aesthetic smile arc.

number and position of the perforations conducted. In
addition, MOP was also conducted distal to the maxillary second molars to maximise molar intrusion. Treatment with 49 aligners was completed (Figs. 1f–h) in seven
months and three weeks on a schedule of three- to ﬁveday aligner exchanges, dependent upon the patient’s own
determination of appropriate aligner tracking. Based upon
experience with cases of a comparable nature where MOP
was not used, use of MOP in this patient resulted in exceptional and uninterrupted aligner tracking, achievement of
all treatment goals to the patient’s satisfaction, and a treatment time truncated by approximately ﬁve months.

In order to support the intrusion mechanics, MOP was
conducted in both arches and supported further by the
patient’s use of rubber gum. Figures 1c–e illustrate the

Case 2: Occasionally, more complicated cases will
require more than one MOP procedure. In my experience, the average MOP procedure will permit a three-

Fig. 1c

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| technique

Fig. 1d

Fig. 1e

Fig. 1g

Fig. 1f

Fig. 1h
Fig. 1d: Treatment sites. Fig. 1e: Immediately after treatment. Fig. 1f: Before and after. Fig. 1g: Merged Ceph/Pan. Fig. 1h: Final.

day aligner exchange from three to four months. Where
cases are anticipated to extend beyond 50 aligners due
to more challenging tooth movements, I then incorporate
a second MOP procedure into the treatment plan. For
example, in Figures 2a and b, a 28-year-old male patient
presented for orthodontic consideration with a vertical
Class III skeletal malocclusion characterised by bimaxillary arch constriction, an anterior/posterior crossbite
from the left lateral incisor to the left second bicuspid, retroclined and extruded mandibular incisors, a mandibular
shift to the patient’s left of 3.5 mm, a 1 mm overjet and a
10–15% overbite. A treatment plan including two adjunctive MOP procedures and Invisalign with 3/16 in., 6 oz
Class III elastics was accepted by the patient. The treatment included broadening of the arch form, correction of
the crossbite, intrusion of the mandibular incisors with the

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application of 15° lingual root torque, and intrusion of the
posterior teeth to create a mandibular hinge axis of closure of the mandible, to achieve incisal guidance without
altering the patient’s maxillary incisal display or extruding
the mandibular incisors. In addition, an aesthetic smile
arc was planned.
The ﬁrst MOP procedure was conducted at aligner 1,
and the patient exchanged aligners every three to seven
days, dependent upon the patient’s own assessment of
satisfactory aligner tracking throughout the initial set of 45
aligners. The second MOP procedure was conducted at
aligner 1 of reﬁnement (Fig. 2c), and the patient exchanged
aligners at the same rate of exchange throughout the
next 38 aligners. Following with a total of 83 aligners,
the patient completed aligner treatment in 16 months

[33] => ortho_1_2018.indb

technique

Fig. 2a

Fig. 2b

Fig. 2c

Fig. 2d

|

Figs. 2a & b: Initial. Fig. 2c: Commencement of reﬁnement prior to 2nd MOP procedure. Fig. 2d: Final.

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| technique

Fig. 2e
Fig. 2e: Final.

(Figs. 2d–e), followed by an additional two months of elastic
wear with four additional passive aligners (exchanged
every two weeks), for a total of 18 months total treatment.
Although all patients are interested in reducing their
treatment time, some are not amenable to MOP. For these
patients, any adjunctive non-surgical device that has the
potential to reduce treatment time by 25–30% has been
demonstrated in surveys to be of interest.4 While the
science supporting vibration as an adjunct for tooth movement is sparse, HFV technology appears to be a potentially viable alternative for these patients. Clinical experience has demonstrated HFV’s capacity to enhance aligner
seating, which is particularly important with patients that
fail to wear aligners the recommended 20–21 hours per
day. The ability to progress treatment forward with less
than fully compliant patients results in a reduction in midcourse corrections and reﬁnements, and thus in effect secondarily reduces treatment time. Moreover, these devices
have demonstrated the additional capacity to reduce the
discomfort associated with tooth movement.10
Case 3: The following example is illustrative. In
Figures 3a and c, a 64-year-old female patient presented
with a Class I malocclusion characterised by moderate
incisor crowding, a 30% overbite and a 2 mm overjet. She
initially agreed to MOP, but changed her mind at aligner
delivery. In addition, she refused any attachments. However, she elected to use a VPro5, a high-frequency aligner

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seater device (Propel Orthodontics) for ﬁve minutes daily
and to wear the aligners 21–22 hours per day. With a
seven-day aligner exchange, her estimated treatment
time was approximately eight months and two weeks.
Treatment with 33 aligners was completed in ﬁve months
and three weeks with a ﬁve-day aligner exchange, which
is a decidedly 30% truncated treatment length when
compared with the original anticipated treatment using a
seven-day protocol. In addition, the patient indicated that
the discomfort associated with new aligner exchange
was immediately alleviated with the HFV seating device,
and enabled her to progress with a truncated aligner
exchange without discomfort. The patient was satisﬁed
with her result and rejected any reﬁnement.
Case 4: Over the past two years, I have used MOP in
combination with the HFV aligner seating device. The following is an example of these cases. In Figures 4a and b,
a 60-year-old female patient presented with a Class I malocclusion characterised by bimaxillary constriction manifested as severe maxillary and mandibular crowding, and
a deep bite (80% overbite) with severely retroclined and
super-erupted mandibular anterior, and a steep interincisal angle (158°) outside of the physiological range.
The treatment plan included 3 mm intrusion of the mandibular incisors and 1 mm extrusion of the maxillary lateral
incisors, to preserve the patient’s incisors display while
creating an aesthetic smile arc. MOP was conducted
from the distal aspects of the ﬁrst premolar in both arches,

[35] => ortho_1_2018.indb

technique

Fig. 3a

|

Fig. 3b

Fig. 3c
Fig. 3a: Initial. Figs. 3b & c: Final.

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35

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| technique

Fig. 4a

Fig. 4b

Fig. 4d

Fig. 4c
Figs. 4a & b: Initial. Figs. 4c & d: Final.

and supplemented with the use of the HFV device for ﬁve
minutes per day. Prior to the procedure, the patient was
instructed on recognising appropriate aligner tracking.
As shown in Figures 4c and d, treatment with 79 aligners (43 initial, 22 ﬁrst reﬁnement, 14 second reﬁnement)
was completed in 13 months and three weeks (compared
to the anticipated treatment time of 19.5 months without acceleration). The use of MOP in combination with
the HFV device resulted in exceptional aligner tracking

36

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throughout treatment, patient comfort with the accelerated aligner exchange of every three to six days, and a
treatment time truncated by almost six months.

Discussion and conclusion
In spite of a growing body of both laboratory studies and clinical reports investigating the effects of pulse
vibration devices—both low- and high-frequency—

[37] => ortho_1_2018.indb

technique

on the rate of tooth movement, the inconclusive and
sometimes conﬂicting results, compounded by methodological heterogeneity, have made it difﬁcult to critically assess the evidence. It is of critical importance to
recognise this, in order to avoid misleading practitioners
into promoting clinical outcomes to their patients that are
specious. The paucity of high-quality randomised clinical trials is problematic. Moreover, this challenge is compounded by the trend of manufacturers directing patients
to their orthodontic products rather than through orthodontic practitioners, as well as to selected clinicians
that promote these products.10 An emergent scientiﬁc
observation, for it to become an objective fact, whether
or not it is accepted, requires more than a handful of
selective scientiﬁc research. It requires a whole system
of research all pointing in the same direction and towards
the same consequences. In the absence of a body of
science-based evidence, there, nevertheless, remains
an increasing volume of clinical reports that illustrate the
potential value of these accelerated modalities.
Precise aligner seating is not only integral to the
clinician’s anticipated treatment schedule, but it also
prevents teeth from moving in an undesired or unanticipated direction within the aligner, due to a less than
adequate ﬁt. Successful tracking is fundamental to
accelerated aligner exchange. HFV pulse vibration
devices such as the VPro5, have clinically demonstrated
the capacity to enhance tracking and tooth movement,1
assuming appropriate diagnosis, treatment planning
and Clincheck design.
An especially particular beneﬁt of this HFV device is
that patients only need to use it for ﬁve minutes per day,
which is conducive to patient compliance. Moreover, it
appears to be of beneﬁt with tracking in patients that
are less than compliant with the mandated 20 hours
per day aligner wear protocol. A recent study demonstrated a signiﬁcant 99.6% patient compliance rate with
the ﬁve-minute HFV device.11 My own experience with
a low-frequency vibration device wherein the manufacturer designated a mandatory 20 consecutive minutes
of use, resulted in a compliance rate of only 10%, which
led me to abandon its use.
During the ﬁrst few hours or days of aligner exchange,
some discomfort is expected. The HFV device has elicited a positive response from a majority of patients, with
some patients claiming that its use immediately following
aligner exchange, results in complete resolution of discomfort. Congruently, a recent study using the device
in aligner therapy demonstrated a statistically signiﬁcant
immediate reduction in recorded pain scores, versus
controls within ﬁve minutes of aligner exchange, as well
as over a seven-day period following aligner exchange.11
Accordingly, it appears that many patients beneﬁt from
use of the device in discomfort modiﬁcation.

Because the MOP procedure is entirely cliniciandirected, it does not rely on patient compliance outside
of the ofﬁce to generate its effects. It therefore provides
an opportunity to more readily appreciate its capacity to
accelerate aligner treatment, and consequently remains
the gold standard for acceleration in our practice. Moreover, based upon clinical experience, it appears that the
combination of MOP and HFV devices provides a possible
synergistic effect, where the capacity to exchange aligners
every three days is extended over a greater period of time,
as opposed to instances where MOP alone is used. The
beneﬁts of decreased treatment time with enhanced predictability and clinical outcomes are of importance to clinicians and patients alike. Within the past two years, we have
experienced patients who have presented for treatment
through patient referral, proactively requesting the MOP
procedure as an adjunct to their aligner treatment. The
use of these accelerated devices in clinical practice has
the potential to augment the quality of care, patient acceptance of, and satisfaction with orthodontic treatment. Several years ago, these acceleration modalities had signiﬁcantly inﬂuenced my practice. Now, they have deﬁned it.

Acknowledgement
The Excellerator is the ﬁrst and only device cleared by
the US Food and Drug Administration (FDA) for microosteoperforation in orthodontic and dental operative procedures. Propel Orthodontics markets the VPro5, the ﬁrst
and only high-frequency vibration aligner seater. Propel
Orthodontics provided ﬁnancial support to the author.
Editorial note: A list of references is available from the
publisher.

about
Dr Gary Brigham
is a Top 1% Super Elite provider of
Invisalign and has been an Elite provider since its inception. He has lectured
across the US to doctors on all aspects
of Invisalign treatment since 2004. In
addition to his Doctor of Dental Surgery
degree and Orthodontic Specialty Certiﬁcation, Dr Brigham earned a Master
of Science degree in Immunology at Case Western Reserve
University in Cleveland, Ohio, in the US. For his research, he
was presented with the Harry Sicher Research Award by the
American Association of Orthodontists. A former Assistant Professor of Paediatric Medicine at the University of Illinois Medical
Center in Chicago in the US, Dr Brigham currently serves as
an adjunct professor and is the dedicated Invisalign and Propel
instructor in the Graduate Orthodontics Program at A.T. Still
University in Mesa, Arizona, in the US. In addition, he practises
in Scottsdale and Cave Creek in Arizona, where he has treated
1,967 patients (including over 672 teens) with Invisalign.

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[38] => ortho_1_2018.indb

| industry report

Indirect bonding: Digital technique
vs conventional method
Drs Arturo Fortini, Alvise Caburlotto, Elisabetta Carli, Giulia Fortini & Francesca Scilla Smith, Italy

One of the peculiar features of straight-wire techniques is
the in-built tip, torque and in-out adjustments in the brackets, which reduces the need for making ﬁrst-, second- and
third-order bends on the arch. It follows that the precision

Fig. 1
Fig. 1: Dental studio-Ortho Studio Module.

38

ortho
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in the positioning of the brackets is of fundamental importance for making the correct adjustments and for the consequent predictability of the result, thus making bonding
one of the most important steps of the whole treatment.

[39] => ortho_1_2018.indb

industry report

Fig. 2

Fig. 3

Fig. 4
Fig. 2: Indirect bonding though Leone’s JIG and brackets. Figs. 3 & 4: Limitations of the conventional method, such as non-constant accuracy and excess of
composite around the base of the attachment.

With direct bonding, there is a high margin of error in
bracket positioning, due both to the dental professional’s
experience and to difﬁculty with visualisation. The positioning errors that can be made are on the horizontal,
vertical and mesiodistal axes, and can create the need
to reposition the brackets during orthodontic treatment,
resulting in a waste of time. Over the years, indirect positioning techniques have been developed to make positioning more precise and to make the procedure as fast
as possible. The aim of this study was to compare a new,
digitally assisted method of indirect bonding (Transfer Bite
Leone) with the conventional clear two-tray technique,
using the split-mouth method to evaluate the amount of

remaining composite around the base of the bracket in
both procedures.
In order to avoid differences due to placement, we
used the same dedicated programme for both methods. STL ﬁles, obtained from intra-oral arch scanning
or stone model scanning, were loaded and processed
with the Leone Maestro 3D Ortho Studio software (AGE
Solutions). This digital tool permits the segmentation
and width and height measurement of the teeth, and
the subsequent determination of the long axis and the
average height of the clinical crowns, in order to virtually
arrange the brackets in the correct position. The den-

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[40] => ortho_1_2018.indb

| industry report

Fig. 5
Fig. 5: Leone’s Transfer Bite system.

tist can later change the positioning height, the torque,
the tip and the rotation to obtain an absolutely individualised and strategic positioning of the brackets for the
case (Fig. 1).
Once the ideal position of the brackets had been
obtained, we used the Maestro 3D software to obtain a
ﬁle that allowed the 3-D printing of the model in which,
in the left hemi-arch, the brackets were integrated to be
able to use it to produce the conventional thermoformed
clear trays that would contain the brackets to be placed in
the mouth. In the right hemi-arch, using the software, we
designed a Transfer Bite that permitted precise positioning of the brackets. The Transfer Bite is made of biocompatible material and is produced using a high-precision
3-D printer according to speciﬁc parameters.
Our split-mouth clinical investigation protocol was
accepted by the American Association of Orthodontists committee for the table clinics that we presented
at the 2017 annual congress in San Diego in the US
(Fig. 2). This procedure clearly demonstrated the limitations of the conventional two-tray technique: inconsistent
accuracy, an excess of composite around the base of
the bracket that cannot be removed during the bonding
step, and difﬁculty in removing the thermo-printed support (Figs. 3 & 4).
The Transfer Bite system with positioning devices was
found to be better because it allows the clinician to have
a complete view of the base of the brackets, optimising the removal of excess composite (Fig. 5). In addition,
the Transfer Bite, compared with the thermoformed trays,
has greater stability on the dental arches, with an even
better precision result, and aids the dentist in repositioning the brackets in a detachment case.

40

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Our experience of using the Transfer Bite system on
12 patients allows us to conﬁrm that this new indirect
bonding method is simpler, easier and more accurate
than the conventional method. Furthermore, it proved to
be a less operator-dependent technique, allowing even
less-experienced clinicians to achieve optimal results.

about
Dr Arturo Fortini
is a specialist in orthodontics and in
private practice in Florence in Italy.
He is a visiting professor at the University of Cagliari and University of Rome
Tor Vergata, both in Italy. He can be
contacted at arturofortini@gmail.com.
Dr Elisabetta Carli
is a specialist in orthodontics and in private practice in Fivizzano
in Italy. She can be contacted at elisabetta.carli@gmail.com.
Dr Alvise Caburlotto
is a specialist in orthodontics and in private practice in Venice
in Italy. He can be contacted at a.caburlotto@gmail.com.
Dr Giulia Fortini
is a specialist in orthodontics and in private practice in
Florence. She can be contacted at giulia.fortini2@gmail.com.
Dr Francesca Scilla Smith
is a specialist in orthodontics at Nova Southeastern University,
College of Dental Medicine, in Fort Lauderdale in the US.
She can be contacted at dr.francescasmith@gmail.com.

[41] => ortho_1_2018.indb

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| industry report

Hybrid Aligner Therapy
Dr Wajeeh Khan, Germany

Introduction

Studies on treatment efﬁcacy with aligners

The orthocaps Hybrid Aligner Therapy (HAT) is a treatment option that broadens the indications of aligner treatments. This technique makes aesthetic treatment possible for almost all malocclusions, without the need for
complex labial or lingual systems. It also helps to reduce
the number of treatment steps and treatment duration as
a whole. Complicated tooth movements can therefore be
carried out more effectively and quickly.

Clinical studies to date, have mainly focused on one
aligner system, which has dominated the market since
1999 namely, Invisalign. There are, however, no independent studies on the efﬁcacy of other comparable aligner
systems, such as orthocaps, ClearCorrect and eCligner.
Differences in the treatment results between the systems
mentioned should be expected, since there are differences in the respective concepts, workﬂows and materials
used. Apart from that, the known general limitations of all
removable thermoplastic appliances apply. A few studies
that point to these limitations are discussed in this article.

In 1950, Elsasser published an article on the use of the
Kesling positioner: “H. D. Kesling developed the concept
of an appliance capable of moving teeth without brackets, bands or wires... This was the beginning of a new
treatment concept using tooth positioners.”1
More and more patients today, want invisible orthodontic treatments instead of conventional ﬁxed braces, yet
still expect equivalent results. This increased demand for
modern aligners or lingual appliances that we see today,
was predicted by Kesling over 70 years ago and was also
one of the motivations in developing his appliance.

Limitations of lingual appliances
The advent of modern lingual appliances, ﬁrst introduced in 1967 by Kinja Fujita and developed further in the 1970s in the US, is the result of an everincreasing demand for aesthetic alternatives in clinical
orthodontics. The disadvantages of lingual appliances
compared with conventional labial multi-band/multibracket appliances are high labour costs, reduced
inter-bracket distance, difﬁcult access during wire
changes, speech problems, tongue irritation, complicated handling of the appliance and irregularities of
lingual tooth surfaces.

Limitations of aligner-based systems
The main limitation of aligner-based systems, is the fact
that they involve a removable appliance which cannot
work unless worn by the patient as prescribed. A prerequisite therefore, is maximum patient cooperation.
Another limitation is the difﬁculty of achieving targeted
and constant orthodontic forces throughout the treatment. Attachments are therefore essential to transmit the
right forces to correct malpositions.

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Djeu et al. demonstrated that Invisalign did not perform as well as ﬁxed appliances in a comparison group
with malocclusions.2 The Invisalign group lost 13 objective grading system points compared with the ﬁxed appliance group.2 The success rate with Invisalign was 27%
lower than the success rate with ﬁxed appliances.2 The
aligner system was shown to have advantages in the closure of small gaps and anterior tooth rotations.2
According to Phan and Ling, the Invisalign appliance
can be used with limitations in patients with simple malocclusions.3 Furthermore, it was demonstrated that
results are more difﬁcult to achieve in comparison with
ﬁxed appliances.3 It was also mentioned that a combination of this aligner with ﬁxed appliances could shorten
treatment duration and improve results.3
Kravitz et al. showed that the mean accuracy of tooth
movements was 47.1% with Invisalign.4 The least accurate movement was extrusion of the maxillary central
incisors (18.3%) and the mandibular central incisors
(24.5%).4 Accuracy decreased signiﬁcantly with rotations
of more than 15°.4
According to Simon et al., the mean success of tooth
movement with Invisalign was 59%.5 The mean accuracy
of incisor torque was 42%.5 Premolar de-rotation showed
the lowest accuracy, of approximately 40%.5 Distalisation
of the maxillary molars was achieved in 87% of cases.5
The extent of the planned movements and the staging
had a signiﬁcant inﬂuence on the treatment result.5
In a review of 271 publications between April 2005 and
December 2012, ten studies were selected for inclusion

[43] => ortho_1_2018.indb

industry report

in a systematic review.6 From these, it was concluded that
Invisalign is suitable as an effective method for closure
of minor gaps, lingual constriction and correction of anterior rotation.6 However, it found that this system did not
appear to be able to correct antero-posterior discrepancies, occlusal contacts, extrusions and rotations of more
than 15°.6

Hybrid Aligner Therapy concept
Orthodontists have been combining multi-band appliances with aligners for quite some time, in order to compensate for certain limitations that are to be expected
with aligner treatment alone. The new concept of HAT is
based on the idea that part of the movements planned
in aligner treatment, can be carried out with ﬁxed partial appliances to achieve aesthetic, effective treatment.
This method therefore allows for concomitant use of
two conceptually and mechanically different appliances,
through which an effective treatment can lead to better
clinical results. The exact times, modalities and use of
the common lingual ﬁxed auxiliaries can be determined
in the treatment plan. Aligners can only be used successfully for severe, protracted or complicated movements in
combination with auxiliaries. A large part of the movement is achieved with the aligners, while auxiliaries are
used as needed, primarily as support. Auxiliaries can be
used during three different treatment phases.
1. Pre-aligner treatment auxiliaries
Certain distalisation, expansion and constriction appliances can be used as part of a comprehensive treatment
plan before the initial use of aligners. Examples include
such appliances as the Beneslider, Wilson lingual arch,
quadhelix, hyrax expander and trans-palatal arch.
2. Intra-aligner treatment auxiliaries
The most important part of the HAT is the integration of
auxiliaries with concomitant use of aligners. A signiﬁcant
portion of these auxiliaries is composed of lingual partial appliances, which are indirectly bonded to the lingual
tooth surfaces. These modules are composed of lingual
brackets and wires, on which the aligner can be placed
in a custom-ﬁt way. The movement of teeth is controlled
by the interaction between the aligner and the ﬁxed modules. Teeth that serve as anchorage units, are ﬁxed by
the aligner placed on top of them, while teeth that must
be shifted are moved by the special cavities or movement channels with in the aligner in a targeted manner.
Figure 1a shows the starting position of the teeth prior
to aligner treatment, and Figure 1b shows the situation
prior to placement of the auxiliaries in order to accelerate the treatment process and de-rotate the canines. Figures 1c to h present the further treatment process up to
the end result.

Virtual brackets and wires were part of the treatment
plan according to our concept. The sequential movement that should be achieved by the aligner and the
planned movement induced by the ﬁxed partial appliances are synchronised using computer technology. The
extent and the distance of the movement of the auxiliaries can be mapped and simulated using 3-D tracking.
This technique can be reviewed in detail in the relevant
patent speciﬁcation (process for the production of an
orthodontic set-up, WO 2014135599). Tooth movements
can also be made possible by creating suitable movement channels within the aligner using special computer
processes.
Creating ﬁxed auxiliaries
Virtual modules (brackets and wires) are placed on a
virtual set-up model (Fig. 2a). The teeth with the ﬁxed
attachments are then returned to the original position
(Fig. 2b). The data gained in this way forms the basis of
the real models, which are necessary for the fabrication
of the transfer tray. The auxiliaries are ﬁxed to the teeth
using the transfer tray. Special brackets (i-TTR, Rocky
Mountain Orthodontics) with rounded contours and
without undercuts allow for easy handling in combination with aligners (Figs. 3a–d).
With the i-TTR bracket, up to three archwires can be
used. The central slot can receive a 0.016 × 0.022 in.
archwire (ribbon-wise), while two rounded archwires
(maximum of 0.016 in.), one gingival and one incisal,
can be pulled under the wings. The possibility of using
archwires on three different vertical levels signiﬁcantly
broadens the spectrum of use. Heat-activated nickeltitanium archwires are ideal for this purpose. Once the
teeth have been partially straightened, another archwire can be used in another slot in order to sustain the
movement. This makes a change to a stronger archwire
unnecessary.
Pre-activated and pre-loaded auxiliaries for faster and
easier use are already being developed by the Ortho Caps
company. With this variant, it would no longer be necessary to ligate the archwires after attaching the brackets,
as these pre-loaded archwires together with the brackets
would be provided via the transfer tray as a single unit for
indirect bonding.
3. Post-aligner treatment auxiliaries
Using aligners for the orthodontic closure of gaps in
extraction cases is a great challenge, since the adjacent
teeth may tip into the extraction space. Once the space
closure has been completed with aligners, special auxiliaries help to upright the roots. Another special auxiliary
for anterior tooth torque after aligner treatment is currently in the trial stage at Ortho Caps.

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[44] => ortho_1_2018.indb

| industry report

Fig. 1a

Fig. 1b

Fig. 1c

Fig. 1d

Fig. 1e

Fig. 1f

Fig. 1g

orthocaps BiteMaintainer for ﬁnishing and retention
The treatment concept discussed, which entails the
combination of different techniques and appliances, can
also be used for the ﬁnishing and retention phase. Use
of a bite maintainer may also be advantageous in special cases, for example for functional occlusal balancing,
occlusal interferences and undesirable lateral malocclusion caused by aligner treatment.
The orthocaps BiteMaintainer is a type of positioning
device made from dental silicone. For cases treated with
the orthocaps system, only a lateral cephalometric radiograph, along with centric bite registration, is needed. The
design for the BiteMaintainer is modelled in a CAD software after the localisation of the mandibular hinge axis
(Fig. 4). This method not only saves time for the ortho-

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Fig. 1h

dontist, but also allows for an exact reconstruction compared with former methods. The BiteMaintainer can be
used as a retention device and a ﬁnishing device.

Discussion
As the history of orthodontics shows, most of the
techniques and appliances used today, including the
aligner, are not new concepts or even inventions. We
also know as orthodontists, that every technique and
every appliance has its advantages and disadvantages.
In order to offer our patients the best possible treatment
that delivers a guaranteed good long-term result that
is both aesthetically and clinically acceptable, we must
make the most of all techniques and appliances. The
orthocaps HAT uses modern technologies that integrate
various treatment processes and methods in order to

[45] => ortho_1_2018.indb

industry report

Fig. 2a

Fig. 2b

Fig. 2c

Fig. 3a

Fig. 3b

Fig. 3c

Fig. 3d

Fig. 4

provide improved, simpler solutions for the planning and
execution of treatment.
The methods discussed here broaden the indication
for the orthocaps aligner system and avoid some of the
inherent limitations that all aligner systems share. With
the use of the orthocaps HAT, the number of treatment
steps and the treatment duration are reduced. HAT
also allows for invisible aligner treatment and demonstrates efﬁcacy and shorter treatment time in complex
cases. The results achieved with this method are comparable to those of conventional lingual or labial appliances.
Editorial note: This article was ﬁrst published in the
December 2015 issue of KOMPENDIUM.

|

about
Dr Wajeeh Khan
is a specialist in orthodontics and runs
a private orthodontic practice in
Hamm in Germany. He is the Managing
Director and Chief Executive of Ortho
Caps. Khan is a member of the German
Orthodontic Society, French Orthodontic Society, Deutsche Gesellschaft für
Linguale Orthodontie [German society
for lingual orthodontics] and American Association of Orthodontists. He is a Fellow of the World Federation of Orthodontists.
Khan regularly conducts lectures at symposia and universities
in Europe. He can be contacted at info@orthocaps.de. |
www.orthocaps.de

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| interview

Digital smile design meets
orthodontics: Full-day course
closes second EAS Congress
Interview with Dr Christian Coachman
By Nathalie Schüller, DTI

According to Dr Christian Coachman, orthodontics
is a specialty that should be integrated into digital smile
design (DSD) and it is essential to understand the importance of this. For better DSD, it is necessary to understand
orthodontics as a specialty, ﬁrstly, to know which cases
could beneﬁt from tooth movement and how, secondly,
to convince the restorative dentist about this beneﬁt,
and lastly, to help the dentist educate and motivate the
patient about this option, to increase case acceptance.
Because to Coachman aligners are the future when it
comes to moving teeth, coming to Venice in Italy for the
second Congress of the European Aligner Society (EAS)
was a good opportunity to participate in an event dedicated to aligners and orthodontics. He presented a postcongress course on DSD and aligners, with a whole-day
programme of lectures and a live patient demonstration.
Dr Coachman, you just arrived in Venice, so thank
you for taking the time to sit and talk with me. I’d like
to start by asking how you got started in dentistry
and later the DSD concept.
I started in dentistry because my whole family is in
dentistry. My father, my uncle, my grandfather are all
dentists. I decided just to follow in that line. My father
never pushed me to follow in his tracks. As a teenager,
I never went to his ofﬁce or thought of becoming a dentist; it was more a last-minute decision for me to try
dental school. My dream was to become an architect
and designer, but for some reason, I decided that I would
probably have a better life if I was to become a dentist. I
don’t remember why I picked dentistry over architecture;
it feels now as if I just ended up in dental school.
Anything related to art and visual skills always attracted
me and, somehow, maybe my intuition, lineage, guided
me to decide to go into dentistry. So I picked dentistry
without knowing that I could become an architect of the
smile and it took me a few years to actually ﬁnd myself
happy in the dental profession.
At ﬁrst, I thought I had made a mistake. I did not enjoy
the beginning of my dental studies, and once I ﬁnished
dental school, I went on to art school because I realised
I did not want to become a dentist, but in my ﬁrst year of
art school and with teachers explaining the principles of

ortho
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harmony, proportion, design, arrangement and illusion,
the ﬁrst thing that came to my mind was the smile. I realised I could be an artist of the smile and went back to
dentistry and started DSD. One never knows how destiny
will guide you. One just has to trust that everything happens for a reason.
It seems that many dentists specialised in restorative
dentistry have either studied or worked as dental
technicians. Do you think it is a prerequisite for
becoming a great restorative dentist or is it enough
if one works with a talented dental technician?
It is impossible to be a good restorative dentist without
understanding dental technology. Many dental technicians have gone to dental school to become dentists.
The difference for me is that I was both, but decided
to keep working as a dental technician. Most people
become dentists who are also dental technicians, but I
did the opposite. It gave me the opportunity to work with
many great dentists and partner them as a technician.
In this way, I worked with most of my mentors and that
was an interesting decision because it made me unique.
Even though I could work as a dentist, I prefer to work as
a technician for a dentist.
This knowledge and understanding of the other’s specialty allows for better and faster communication. We can
create plans together at a different level.

[47] => ortho_1_2018.indb

interview

I think that, before being a very good specialist, one
needs to be an amazing generalist. One needs to understand a little bit of everything, have a comprehensive,
global understanding. It is then possible to choose what
we like the most and specialise in that ﬁeld. The problem
is that sometimes people specialise without seeing the
big picture and I think it is a limitation.
What do you see as being the most important skill or
skills to become a smile designer?
A problem in dentistry that we need to address is the
separation between the specialties. An example would
be that, for me, it is a great honour to be here. Orthodontics is a new world to me. It makes me understand, realise, that I knew very little about it and orthodontists know
very little of my world, restorative dentistry. We need to
close this gap and that is one of the things that are very
important to become a smile designer.
If one is an orthodontist, one is a smile designer; if one
does restorative dentistry, one is a smile designer; if one
performs orthognathic surgery, one is a smile designer,
but a true smile designer connects everything, and unfortunately, there is still a separation. We need to understand
better that the patient does not care what one’s specialty
is. As a dentist, one needs to become an orofacial expert,
to go beyond dentistry, to understand the face, the lip
dynamics, plastic surgery, dermatology, a little bit of all
the specialties, because the patient deserves a comprehensive planning, and to understand what is best for the
patient, one needs an understanding beyond the specialties to have a complete picture. That is the main skill for a
modern smile designer, understanding the big picture. It is
necessary to understand the basics to be able to educate
the patient about the possibilities. I think we will become
modern smile designers when we can understand a little
bit about all these pieces and then be able to work as a
team with specialists in all the different specialties.
Therefore, continuing education is very important. Is
it a requirement in Brazil for dentists?
Unfortunately, it is not an obligation in Brazil. I think
though that the market itself will push people into it. I see
that being a complete orofacial expert makes total sense
for the patient and I think people understand that. When
one goes to a physician, one doesn’t want one who
understands only the area where one’s pain is; one wants
a physician with a greater vision, to understand the connections of one’s pain with one’s whole body. So too with
a dentist: before going to a specialist, one wants a dentist that sees everything and can refer one based on this.
The dentist can help his or her patients much more
than what people imagine. I like the concept of orthodontist Dr William Arnett, who became one of the top orthognathic surgeons. He said that if one wants to become

a real dentist, one needs to take care of the face from
the aesthetic standpoint, the airway because the patient
needs to breath well to be healthy and the bite because
occlusion is essential and that connects the whole body
as well in terms of posture and balance, etc. We need to
extend our vision to take care of all of this.
You are usually at congresses to lecture. Do you
sometimes attend to learn, expand your knowledge?
I don’t know about orthodontic congresses, since this is
one of the ﬁrst I have attended, but in my area, restorative
dentistry, periodontics, implantology, etc., many lectures
are becoming kind of boring because people seem to
have been talking about the same things for the last ten
years. I think an ideal congress should provide three
aspects, three types of speakers: the ultra-specialised
speaker, going in depth about the details and exploring
better ways to do the same things that we have been
doing—usually congresses are too focused on having
these presenters only—and I believe that another third
of the presenters should be generalists who see the big
picture and talk about a comprehensive vision, holistic
integration, for example here connecting the orthodontic world with taking care of the human being as a whole,
health in general, and ﬁnally, another third of the speakers
should be there to talk about innovation, about thinking
outside the box, and trends. These three aspects for me
are important to give quality to a congress.
I am not sure though that what is presented during
congresses is actually widely used by dentists. To
what extent do these trends and new technologies
QD@KKXØÚMCØSGDHQØV@XØHMSNØOQ@BSHBDRØCNØXNTØSGHMJØ(ØCNØ
hope, but am not certain that the digital approach is
as widely used as it should be.
I think there is a tendency to over-complicate things.
The reality on the podium, in research, at universities and
in lectures compared with the reality in the dental ofﬁce,
where one needs to make the patient happy, follow basic
ethical principles, as well as make money and run a business, means one needs to ﬁnd a balance between it all
to deliver care that one can be proud of.
The digital approach is just starting; it is a huge
paradigm shift and it will take time. People ﬁght against
changes and don’t like to change, preferring their comfort zones, but that is not just in dentistry. There is a time
of shift, then there are the early adopters, the people who
have a business vision, who really make money out of
these new ideas, and after a few years, the majority start
to really come on board. That is the process of life. The
smart people and the people who will really beneﬁt from
these changes and innovations are the ones that understand how to incorporate these ideas and create a business model around them.
Thank you very much for your time.

ortho
1 2018

[48] => ortho_1_2018.indb

| industry report
Propel Orthodontics’ Excellerator series drivers and VPro5
Propel Orthodontics is proud to provide both in-ofﬁce and at-home
orthodontic accessory devices to clinicians and their patients. The
Excellerator series drivers, used to perform micro-osteoperforation
(MOP), are doctor-controlled in-ofﬁce devices. The Excellerator is
the only product cleared by the US Food and Drug Administration
for use in micro-osteoperforation The latest driver in the series is
the Excellerator PT, a power driver with optimal torque and speed,
making procedures faster and easier than ever before.
The at-home option, VPro5, is inspiring patients to take an active
role in their treatment. The VPro5 is the ﬁrst and only high frequency
vibration device to support both active treatment and retention in
just 5 minutes a day.

Propel Orthodontics
233 South Highland Avenue
Ossining, NY 10562
US
Tel.: +1 855 377 6735
https://propelorthodontics.com/

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[49] => ortho_1_2018.indb

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[50] => ortho_1_2018.indb

| meetings

Second EAS Congress
proves its worth
From an expected 400, the number of attendees at
the second Congress of the European Aligner Society
(EAS) rose to 550, conﬁrming that, with a committed and
passionate board, the meeting is, indeed, much needed
by dental professionals. The programme included preand post-congress courses, in addition to the general
session, as well as posters and short presentations. The
Journal of Aligner Orthodontics, published by Quintessence, was launched as the ofﬁcial journal of the EAS at
the event, which took place in Venice, Italy, at the Hilton
Molino Stucky hotel from 16 to 19 February.

In the main programme on Saturday and Sunday, international speakers presented on a range of topics. Their
papers covered cases treated with different systems, the
treatment of malocclusions, understanding tooth movement, an interdisciplinary approach to treatment, technical issues such as biomechanics, and digital smile design
and the need for restorative dentistry to understand and
incorporate orthodontics as well. Eleven posters were
also presented during the congress.

Under the theme of “Are you ready to become
invisible?”, the three-day meeting covered current trends,
directions, possibilities and techniques in aligner treatment. It opened on Friday with pre-congress courses and
a short communication programme.

During the plenary session on Sunday, Dr Gabriele
Rossini received the best research award for his
short paper titled “Clear aligner orthodontic optimization through ﬁnite element analysis”. During a full-day
post-congress course on 19 February, Dr Christian
Coachman gave lectures on the digital smile design revolution, with a live patient demonstration.

The EAS concept is to give dentists a platform for
presenting their research and cases. This serves as an
opportunity to discover new talent, but also as a wonderful way for all to be able to present their work, in line
with one of the goals of the EAS: to offer a forum for
showcasing the latest developments in and with aligner
treatment.

Aiming to be the main continuing professional development provider for allied professionals involved in aligner
treatment delivery, the EAS holds educational events,
including its biennial meeting. Before the next EAS
Congress, to take place in 2020, the second EAS interim
congress will meet next year in the spring. The locations
of both events are yet to be announced.

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[51] => ortho_1_2018.indb

meetings

|

Board members: Drs Alain Souchet, Clemens Fricke, Francesco Garino, Graham Gardner and Tommaso Castroﬂorio (Credit: Mauro Calvone).

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51

[52] => ortho_1_2018.indb

| meetings

International Events
11th Asian Paciﬁc Orthodontic Conference – APOC

British Orthodontic Conference 2018 – BOC

5–7 March 2018
Boracay, Philippines
www.apoc2018.org

27–29 September 2018
London, UK
www.bos.org.uk/News-and-Events/Events/BOC-London-2018

26th Australian Orthodontic Congress

Southern Association of Orthodontists 2018 – SAO
Annual Meeting

9–12 March 2018
Sydney, Australia
www.aso2018sydney.com.au

4–7 October 2018
New Orleans, US
www.saortho.org

SIDO International Spring Meeting 2018
16–17 March 2018
Naples, Italy
http://eventi.sido.it/spring2018/

International Association for Orthodontics
Annual Meeting
25–29 April 2018
Kauai, Hawaii, US
https://www.iaortho.org/2018-annual-meeting/

American Association of Orthodontists – AAO
Annual Session
4–8 May 2018
Washington DC, US
www.aaoinfo.org

Paciﬁc Coast Society of Orthodontists – PCSO
82nd Annual Session
11–14 October 2018
Monterey, US
www.pcsortho.org/Educational-opportunities/annual-session.aspx

49th SIDO International Congress 2018
11–13 October 2018
Florence, Italy
www.sido.it/img/media/131845_Congresso_ﬂyer.pdf

77th Annual Meeting of the Japanese
Orthodontic Society – JOS
30 October –1 November 2018
Yokohama, Japan
www.congre.co.jp/jos2018/en/index.html

2018 Latin American Carriere Symposium
30 May –1 June 2018
Cartagena, Colombia
www.carrieresymposium.com

NESO 97th Annual Meeting
2–3 November 2018
Uncasville, US
www.neso.org/meetings-and-education/future-meetings/

94th European Orthodontic Society Congress – EOS
17–21 June 2018
Edinburgh, Scotland
www.eos2018.com

21es Journées de l’Orthodontie
9–12 November 2018
Paris, France
www.journees-orthodontie.org

2018 CAO 70th Annual Conference
6–8 September 2018
Vancouver, BC, Canada
https://cao-aco.org/orthodontics/events/cao-annual-conference/overview/

35th BDO Annual Meeting
23–24 November 2018
Berlin, Germany
www.bdo-jahrestagung.de

10th World Implant Orthodontic Conference 2018 – WIOC
6–8 September 2018
Bali, Indonesia
www.wioc2018.com

5th Scientiﬁc Conference for Aligner Orthodontics
23–24 November 2018
Cologne, Germany
www.dgao.com

2018 European Carriere Symposium
20–22 September 2018
Paris, France
www.carrieresymposium.com

52

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18th International Orthodontic Symposium – IOS
29 November –1 December 2018
Praque, Czech Republic
www.ios-prague.com

[53] => ortho_1_2018.indb

submission guidelines

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Submission Guidelines
Please note that all the textual components of your submission must be
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Please do not submit multiple ﬁles for
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In addition, images must not be
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All images must be submitted separately,
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Text length
Article lengths can vary greatly—from
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topic justice, then please make the article
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We can run an unusually long article in
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In short, we do not want to limit you in
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Please number images consecutively
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An abstract of your article is not required.

Please place image references in your
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Author or contact information
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In addition, please note:
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Nathalie Schüller
(Managing Editor)
n.schueller@dental-tribune.com

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[54] => ortho_1_2018.indb

| international imprint

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ortho international magazine of orthodontics is published by Dental Tribune International (DTI). The magazine and all articles and illustrations therein are protected by copyright. Any

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ortho
1 2018

[55] => ortho_1_2018.indb

[56] => ortho_1_2018.indb

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[cover] => ortho international No. 1, 2018

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Table of contents

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