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Kitabı oku: «Aligner Techniques in Orthodontics», sayfa 4

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1.6.4 Clarity by 3M

The MBT prescription, developed by McLaughlin, Bennett and Trevisi, was successfully marketed by 3M, based in Germany, having developed many innovations in the orthodontic field and including the proprietary Incognito lingual braces system.

In 2018 they launched their Clarity aligners, with the same name they give to their aesthetic braces system, claiming:

 Advanced analytics and software planning tools.

 Open platform accessible with any scanner.

 3M Treatment Tracking patient App.

 Accessibility from PC and MAC.Fig. 1.15 3M superimposition for treatment evolution.

 From November 2019, the only information published in regard to this were two clinical cases published on their website, both for aligning anterior teeth, but with no A/P correction or vertical component in the treatment.

1.6.5 Spark, by Ormco

Ormco is one of the leading brackets and wires manufacturers in the world, which started offering its own aligners brand in 2019, claiming the following (data on file from the Company that we cannot access at this time):

 TruGEN plastic aligner is clearer than the leading aligner (AKA Invisalign).

 TruGEN plastic aligner produces higher sustained force retention in order to reach treatment goals faster than the leading aligner (AKA Invisalign).

 Hand trimmed aligners, with scalloped edges that are meant to be more comfortable for the patient.

Apart from this, their product portfolio is similar to the one developed by Align Technology, with 3 treatment options (10, 20 or unlimited aligners), based on a 7 day wearing period of the aligners. They have as an advantage, the ability to perform single arch treatments using the unlimited aligners product, which is not available for Invisalign aligners.

In regards to their proprietary software, it has different functionalities than ClinCheck software, the most significant being the simulation of roots. None of this has been through a clinical study or published in any journal so, even though these aspects are promising, we will have to wait to see how it develops in the future.


Fig. 1.16 Ormco results for their TruGEN plastic against SmartTrack (data on file).

1.6.6 CA Clear Aligner by Scheu

This German aligner system enables clinicians to fully take control of aligner production, provided that there is a dental technician in the team responsible for developing models and manufacturing in‐office vacuum aligners that offer several advantages:

 Integration of auxiliaries, such as expansion screws or distalizers

 Scheu biocompatible material

 Individual fabrication for each treatment step

 Three thicknesses available (0.5, 0.65 and 0.75 mm) to be changed selectively in order to exert certain forces


Fig. 1.17 Distalizer inserted in an in‐practice aligner.

This is one of the segments that might grow in the near future when 3D printing allows direct aligner printing in the practice, thereby reducing the need for vacuum models, saving both time and money and making it cheaper to produce aligners. This will improve the affordability of the treatments for patients, as this option already provides a fit equal to that of any other aligner brand.11

1.6.7 Irok

This US Company is focused on the printing of digital models for aligners design, but also for retainers, indirect braces bonding.


Fig. 1.18 Irok is focused on digital models that can serve different purposes.

Its unique characteristic is that it provides the possibility of aligning in combination with dental implant software, based on the implant’s final position, and it can be placed with a surgical 3D splint.

1.6.8 Angelalign

Founded in 2001 by Li Haumin in conjunction with Tsinghua University and Beijing Capital, Angelalign is the largest provider of transparent teeth aligners in China.

Since 2006 they have been granted 80 patents relating to processes, aligners, manufacturing and 3D technology and, for these reasons, they can offer a product with several technological advancements and functionalities through their iOrto platform:

 masterMulti, offering the opportunity to using different aligner thickness

 Mandibular advancement device, first launched globally, in 2015

 a7 extraction technology, tested over 15 years

Together with other Asian companies such as Smartee, for whom there is currently little information in Europe, Angelalign will probably become an important stakeholder in aligners development.


Fig. 1.19 A6 mandibular advancement launched in 2015.

1.6.9 Alineadent

This Spanish aligner Company has its origins in a dental laboratory specializing in orthodontic functional appliances, which led to the development of this aligner brand. Its characteristics are:

 Open system, compatible with any scanner brand

 Immediate validation from a dental technician

 Planning within 72 hours

 Production within 72 hours

 LineDock software for case management

Unfortunately, there is no evidence available with regard to its capability in the management of complex cases, as with some other dental companies manufacturing aligners. Their ability to improve this may rely on their approach to practitioners that may choose to use them in cases of minor tooth movements.


Fig. 1.20 LineDock software.

1.6.10 Remote Aligner Companies

It is important to mention direct to consumer aligners, or remote aligners initiatives, especially as Candid, one of these companies, has raised $78.4M in venture capital funds, and SmileDirectClub already has more than 300 locations in the US, UK and Australia and has treated more than 650,000 patients since its foundation in 2014.


Fig. 1.21 SmileDirectClub self‐polyvinyl siloxane (PVS) ‐impression kit.

They all are based on the following workflow:

 Scanning in a company facility similar to a store or self‐taking a polyvinyl siloxane (PVS) impression at home with a kit sent from a remote aligner company, and sending it back to its headquarters

 Validating the case at the company aligners production facility

 Patients receive the aligners


Fig. 1.22 CANDID aligners process.

In an era when people are used to a one‐click‐buy, particularly through their Smartphone, and when telemedicine is on the rise as a result of the growth of the internet and wearables that are part of our daily routines, this might sound ‘good’ for patients who want to have a cheaper treatment option, as they are usually three to four times cheaper than an average comprehensive treatment performed by an orthodontist.

There have been several blocks to the success of these companies: for, example SmileDirectClub were forced to pull out of the Spanish market after the Spanish Ministry of Health warned that their system was against Spanish Law, and the American Association of Orthodontists filed complaints with 36 state dental boards and attorney generals alleging specific statutory and regulatory violations.

These systems may lead to health problems in the future for some of their users owing to poor, improper treatment. This may lead to problems that need to be resolved in‐house, resulting a furhter treatment cost on top of the impact on their health.


Fig. 1.23 CANDID aligners set.

1.7 Future of Clear Aligners

The future of clear aligners is, as with everything, unpredictable, but it likely that there will be a strong focus on:

 In‐practice aligners, thanks to the development of 3D printing

 Integration of CBCT with treatment planning software

 Increasing number of laboratories and aligners companies

 Price reduction

What is clear is that, thanks to this, before 2030 100% of the orthodontic treatments will be performed with aligners in every practice in the world, as it is currently in ours.

We should aim to ensure that as orthodontists we are ahead of these changes and share our views and clinical experience with the orthodontic community as a whole so we may help to improve the smiles of everyone.

Notes

1 1 Remensnyder, O. A gum‐massaging appliance in the treatment of pyorrhea. Dent Cosmos. 1926; 48: 381–384.

2 2 Remonsnyder, O. United States Patent 2,479,780, Orthodontic Appliance, Aug. 23, 1949.

3 3 Ponitz, R. Invisible retainers. Am J Orthod. 1971 59(3): 266–272.

4 4 Hinz R. Elasto‐orthodontic system – a development of the positioner. Prakt Kieferorthop. 1991;5(3):179‐88.

5 5 Sheridan JJ, McMinn R, LeDoux W. Essix thermosealed appliances: various orthodontic uses. J Clin Orthod. 1995;29(2):108–13.

6 6 Feder, BJ. ‘Orthodontics Via Silicon Valley; A Start‐Up Uses Computer Modeling And Venture Capital to Reach Patients’. The New York Times, 18 August 2000: p. 1.

7 7 Bush, J. ‘Stealth Braces’. YT Regional Newspapers (August 14, 2001). Retrieved January 9, 2013.

8 8 Lau, G. ‘It has a bracing impact on patients; Align Technology’ May 3; 2004.

9 9 Antelman G. International Directory of Company Histories. St James Press. 2008; 94: pp. 15–18.

10 10 Cowley, DP., Effect of Gingival Margin Design on Retention of Thermoformed Orthodontic Aligners (2012). UNLV Theses, Dissertations, Professional Papers, and Capstones. 1662. https://digitalscholarship.unlv.edu/thesesdissertations/1662.

11 11 Mantovani E et al. Scanning electron microscopy analysis of aligner fitting on anchorage attachments. J Orofac Orthop. 2019;80(2):79–87.

2 Basic Principles with Aligners

Invisalign treatment is an orthodontic technique, not just a product. As such, orthodontic principles of force application, engagement, anchorage and biomechanics need to be applied. However, aligners move teeth differently than fixed appliances do. In order to understand this we need to have a look at how aligners work.

2.1 Forces

Aligners move teeth by exerting a push force. When the aligner is inserted over teeth, the aligner deforms over the teeth and the elasticity in the aligner material pushes the teeth into position.


Fig. 2.1 Forces will be delivered through the combination of plastic and attachments.

Optimized attachments provide an active, flat surface that the aligner may push against to provide effective tooth movements.


Fig. 2.2 Optimized attachments provide an active, flat surface that the aligner may push against to provide effective tooth movements.

2.2 Engagement

Aligners engage teeth by enclosing the tooth in aligner material. The more material wrapped around a tooth, the better the engagement. In teeth with a long clinical crown and larger surface area, there will be better engagement and therefore better expression of tooth movement. In contrast, in teeth with short clinical crowns and less surface area, there is less engagement and less expression of tooth movement.

Fig. 2.3 These crowns allow enough contact from plastic to exert desired forces.


Fig. 2.4 Short clinical crowns might reduce movement predictability.

One way to increase the engagement of the aligner onto teeth with short or small clinical crowns (for example, peg‐shape lateral incisors) is to place an attachment on the tooth.


Fig. 2.5 Quantification of variable aligner material on retention. (Left) Vertical displacement forces (Newtons) of each aligner material during removal from the control cast containing no attachments. (Right) Vertical displacement forces of each aligner material during removal from the cast containing ellipsoid attachments. (Right) Vertical displacement forces of each aligner material during removal from the cast containing bevelled attachments. Each column represents one of the aligner materials tested (CA soft, medium, hard; Essix ACE).1

This is a different approach from the that with braces, which had ‘contact points’ instead of a full surface contact and this should be kept this in mind for a treatment plan to achieve the same results that can be achieved with brackets and wires.


Fig. 2.6 Brackets have a strong small contact point in comparison with a soft big contact surface between aligner and teeth.

2.3 Anchorage

Aligners offer extremely good control of anchorage because the anchoring teeth can become immovable at different stages of treatment. For example, in asymmetric expansion, one side of the mouth can be used to expand the other. Alternatively, in sequential distalization of the maxillary arch, only the second molars in the initial stages of treatment can be distalized, while the remaining teeth in the arch from first molar to first molar do not move in the initial stages and act as an anchorage segment to push the second molar distally for anteroposterior correction.

Fig. 2.7 While second molars are moving, the rest of the teeth are considered as anchorage.


Fig. 2.8 This figure shows a horizontal ‘V’ movement pattern.


Fig. 2.9 The second quadrant is being expanded using the first quadrant as anchorage.

In the G6 first premolar extraction protocol (Align technology), for maximum anchorage, only the canines and posterior teeth are moved in the initial stages of treatment (if anchorage loss is needed to achieve class I, but only up to 2 mm, otherwise the G6 protocol does not apply). The incisors do not move, and they act as an anterior anchorage segment to distalize the canine into the extraction site for space closure. After using some aligners, the second premolar and molars stop moving, and they become the posterior anchorage segment. Canines will move up to one‐third of their total movement and, at that point, incisors retraction will start.


Fig. 2.10 G6 first premolar extraction has a standardized movement sequence.


Fig. 2.11 In this G6 protocol extraction of 14 (from left to right), the posterior sector and canine move first; when the canine has achieved 1/3 of its total movement, incisors can start retruding.

2.4 Case Selection to Start with Aligners Technique

Invisalign is an orthodontic technique that can be used to treat all malocclusions that were previously addressed with brackets. However, in order to develop confidence with the technique, it is paramount in the beginning to follow a suitable learning curve to allow familiarization with the system and working with the following malocclusions is recommended:

 Class I with minor or moderate crowding or spacing

 Half‐cusp Class II with minor crowding

 Class III with minimal overbite/overjet non‐extraction cases

 Deep bite that can be solve by proclination and anterior intrusion (without posterior extrusion)

 Open bite that can be solved by retroclination and anterior extrusion (without posterior intrusion)

 Lower incisors extractions

However, if we are already comfortable and secure treating all types of malocclusions successfully with braces, then why should we change to aligners?

Note

1 1 Dasy H, Dasy A, Asatrian G, Rózsa N, Lee H‐F, Kwak JH. Effects of variable attachment shapes and aligner material on aligner retention. Angle Orthodontist 2015;85(6):934–940.

3 Why Invisalign?

We will explain why we decided to change ouro patients from braces to aligners and the advantages this brought to the growth of our practices and for ourselves.

3.1 Why Did We Begin Prescribing Invisalign in Our Practice?

Our reasons for prescribing Invisalign in our practice are:

 Differentiation: we wanted to be different from other practices that only offered brackets to their patients. Our goal was to have more contented patients in our offices, leading to more positive feedback and producing patients that would become our best ambassadors for referrals.

 Reputation: currently, and especially in Spain, the state‐of‐the‐art treatment within orthodontics is Invisalign, so patients might believe that if you are not confident in Invisalign, then you might not be a good orthodontist.

 Efficiency in our practice:fewer (and shorter) appointmentsfewer emergenciesappointments planned ahead, so staff can use our protocols and reduce chair timefewer staff members needed to attend the same number of patientseasier training for new staff (compared with using brackets and wires).

It was considered that all these elements would result in a more efficient workflow, and they did!

 Aesthetics: patients seek an aesthetic pleasing look, but not just at the end of treatment, as occurs with brackets and wires, so it is much better for them if we can offer those aesthetics during the entire treatment using an almost invisible plastic appliance.

 Up‐to‐date image of practice: it is easier if you show your treatment plan using digital tools and 3D planning using an iTero (intraoral) scanner, the outcome simulator and ClinCheck, especially compared with practitioners who are still showing their treatment plan with pictures and plaster models.

 For the future: this is our real motivation and the most important one for us.

3.2 Our Motivation

Our prime motivation is that we strongly believe that in the not too distant future, Orthodontics will be exclusively based on aligners. Therefore, what we aim to do right now is offer our patients the treatments most practitioners will be offering in a few years’ time. So, why wait if technological advances let us offer this treatment with the same goals and results as brackets and wires? We also believe this will lead us to being considered lead practitioners, further improving our practices.

The first smartphones became available just a decade ago, and it already seems as though they have been with us for a lifetime. Technology is advancing so rapidly that we will experience radical changes in society. As we undergo this rapid change, our old treatments using braces will no longer apply. Technology is creating a new set of rules that will change everything in our way of working: everything that can be digitized and customized will be. We firmly believe that soon no patients will be using braces for orthodontic treatment so, ‘The sooner we transform all our patients into aligner patients, the sooner we will find the right path for our practice growth’.

4 Patient Communication Skills

The first element in our practice driving growth was word of mouth. For this, we developed a communication plan to explain that Invisalign is not just an aesthetic treatment, it is a lifestyle.

4.1 Invisalign Equates to Health, Wellness and Outstanding Results

We focused on communicating to our current patients that we were using a new technique to align the teeth without braces. For this we used the following channels:


Fig. 4.1 Let’s talk about aligner treatment with our patients.

 Verbal in‐office communication

 Digital and paper newsletter

 Social media

After this, we provided them with a change in mindset:

 For parents: health, wellness and guarantee of results

 For teenagers: change everything in your smile without changing your lifestyle


Fig. 4.2 The more Invisalign patients you have, the more Invisalign referrals you will have.