- Email: [email protected]
Applications of controlled local inflammation in aligner treatment
Author’s Accepted Manuscript Applications of controlled local inflammation in aligner treatment Jonathan L. Nicozisis
www.elsevier.com/locate/ysodo
PII: DOI: Reference:
S1073-8746(16)30062-7 http://dx.doi.org/10.1053/j.sodo.2016.10.006 YSODO483
To appear in: Seminars in Orthodontics Cite this article as: Jonathan L. Nicozisis, Applications of controlled local inflammation in aligner treatment, Seminars in Orthodontics, http://dx.doi.org/10.1053/j.sodo.2016.10.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Applications of Controlled Local Inflammation in Aligner Treatment
Jonathan L. Nicozisis, DMD, MS Princeton Orthodontics Princeton Professional Park 601 Ewing St., B-12 Princeton, NJ 08540
[email protected]
Tel
(609) 924-3271
Fax
(609) 924-7098
‘You May Delay, But Time Will Not and Lost Time Is Never Found Again.’ –Benjamin Franklin.
INTRODUCTION It can no longer be argued aligner therapy is the lesser means to provide orthodontic treatment. To still deny it is tantamount to be the proverbial ostrich with its head in the sand. In order to stay relevant the private practitioner should
not hold this denial-driven mindset or procrastinate to embrace the evolving landscape of our orthodontic industry. As aligner therapy advances to make fixed appliances the minority of treatment modalities, clinician’s ability to advantageously augment host tissue response to orthodontic forces in an effort to facilitate tooth movement is also becoming common place 1. More so, the advent of micro-osteoperforations via Propel’s Excellerator technology helps prepare bone and tissue for orthodontic tooth movement. What was once thought of as science fiction has now transitioned into a reality in private practice. Modestly put, an increase in local inflammation via trans-mucosal osteoperforations (Propel Excellerating Technology) promotes osteoclastogenesis, osteoclast recruitment and differentiation. This causes the bone to remodel faster and hence teeth move faster through the bone 2. This process has been proven to be a safe and repeatable procedure that is well-tolerated and accepted by patients, who report minimal discomfort, when compared to orthodontic tooth movement alone 3. In combining aligner therapy with controlled localized inflammation, Propel-aided aligner treatment enables clinicians to proactively deliver better outcomes, in shorter treatment times or to reactively respond to resolve and
complete stubborn and challenging movements. Experience and evidence of either approach has evolved to make Propel-aided aligner treatment to be a valuable, double-edged tool in the clinician’s armamentarium. The scope of this paper is to convey such experience and evidence while attempting to suggest techniques for easy clinical adoption and delivery 4,5,6,7,8.
Brief review of science behind Propel’s Excellorating Technology Orthodontic tooth movement (OTM) is controlled trauma. As such, there is an inflammatory response that is elicited and necessary for OTM to occur. Research shows that without this inflammatory response OTM will not occur. More so, efforts to thwart it will also retard OTM 9. As previously stated, the micro-insults or micro-trauma caused by transmucosal osteo-perforations elicits a localized inflammatory response. It stimulates osteoclastogenesis, osteoclast recruitment, and differentiation. In turn, the bone remodels faster and temporarily becomes less dense. The net result is that the teeth move faster through the bone. There is no recovery time that is necessary following the procedure. There are no sutures to be removed at subsequent followup appointments that would necessitate taking more time off of work or school. There is no swelling that occurs in days following, and thus far, no reported cases
of infection following the procedure. It is a quick and safe procedure that is able to be performed in the clinic without disruption to the office schedule. Reported data suggest this stimulated inflammatory response peaks in 24-36 hours following the procedure and remains elevated only to return to pre-treatment levels 10-12 weeks subsequently. Furthermore, the inflammatory response radiates 6-10mm around each perforation 2. This is significant when it comes to deciding how many perforations to perform. If Propel is used reactively on one or two teeth, it would be beneficial to perform three perforations around (mesial and distal) these teeth to stimulate as much localized inflammation as possible. If, however, one is proactively perforating a whole quadrant, due to the radiating effect, experience has shown that two perforations are sufficient to elicit the desired enhanced bone remodeling response. Currently, there are clinical trials underway assessing the optimal number of perforations necessary to accomplish certain types of movement. At this time of this publication, however, the best practice protocol is described as above. It is necessary to go through the cortical plate of bone and into the medullary bone. Rather than ‘cutting’ the bone or ‘coring’ a sample from the bone, osteoperforations should be thought of as to ‘displace’ the medullary bone. As such, there is minimal physical trauma to both hard and soft tissues, bleeding, and recovery time following the procedure. There are no potential negative sequelae
such as swelling or infections as there can be with other surgical approaches that attempt to augment a patient’s own biological response during tooth movement. To explain the phenomenon by analogy, imagine a block of ice drilled with a handpiece. The ice would be cut and removed leaving a perfectly smooth path where the bur once was, and the remaining ice untouched or un-phased. If this were bone it would respond by a lot more bleeding and coagulation, and also a lot more necessary recovery time for the bone to heal, fill in, and return to homeostasis. In contrast, now imagine slowly twisting a threaded screw into the same block of ice. Rather than coring a hole into the ice like a drill bit, the threaded screw would instead cause radiating fractures in the block of ice. Clinically, this same process creates radiating fractures in the medullary bone. In effect, these radiating micro fractures elicit a larger amount of radiating inflammatory response with much less bleeding and recovery time, compared to boring a hole into the bone. It is this unique characteristic that makes osteoperforations with Propel’s Exelleration technology highly effective and unmatched. As such, patients can go about their daily routine following the procedure without any disruption other than the anesthesia wearing off. Any bleeding has stopped before patients leave the office.(FIG 1.)
Indications for Reactive Approaches for Propel-aided aligner treatment The obvious indications for the reactive approach are to close stubborn extraction spaces or to resolve rotations.(FIG 2) A single application of Propel may assist in resolving these challenges in one visit rather than take 2-3 visits to accomplish the same thing or it may replace the need for additional sets of refinement aligners. For the aligner patient, this means possibly avoiding an extra scan for refinement or additional aligners. It may also help roots track better as the bone is temporarily less dense to enhance the bodily movement. Less apparent indications are protraction of posterior teeth, cant correction of smile lines or occlusal planes, uprighting molars (FIG3), palatally erupting canines, and the like. The merits of using propel assisted aligner treatment in such specific clinical instances can be communicated to the patients by informing them it may reduce the number of office visits, and to complete the treatment or number of refinements by promoting better tracking of the teeth within the aligner. This, of course, is provided that the ClinCheck is designed correctly.
Indications for Proactive Approaches for Propel-aided aligner treatment: whole mouth vs segments depending on mechanics
The most impactful indication for using Propel is to accelerate treatment overall. For the patient the impact is realized with fewer and less frequent visits to the office to complete their treatment. Patients only need to go to the office every three to three and a half months to have the procedure performed and to be given more aligners. Again, this is provided that the ClinCheck is designed to ‘set it and forget it’ from the start.10 With this mindset, the clinician bonds all attachments from the start and keeps them to the end. All IPR is done prior to the scan if access allows, or at refinement after alignment and tissue reaction is assessed. In this fashion, doctors or staff need not open and review ClinChecks during office visits to keep track of what needs to be added or removed at which stage. This is disruptive to seamless integration and scheduling. It is inconvenient to patients.
The astute clinician must decide if the whole mouth needs to be affected or if a segmented approach is indicated. For example, if it is a Class 1 crowding case with lingually inclined buccal segments or posterior crossbites in adults then it would be best to affect all four quadrants going back to the bicuspids or even the molars.(FIG4) If, however, it is a subdivision Class -II or Class-III, then it is only necessary to apply Propel to the offending quadrants that need to be corrected. Another way
to think about it is to assess the etiology of the subdivision and what quadrant needs help in facilitating tooth movement for its correction. For example, in a subdivision Class-III where elastics alone are needed for correction, Propel only needs to be applied once or twice in the upper and lower anterior and only the lower right buccal quadrant. Such protocol will not only help facilitate the diastema space closure, but also help the elastic forces work more effectively on the right for midline and Class-III correction while the alveolar bone is temporarily softened.(FIG 5) Likewise, for a subdivision Class-II case, Propel need only be applied to the offending side to help facilitate elastic forces and tooth movement for better outcomes in faster times.(Fig 6) More so, if anterior crowding only need to be corrected and the buccal segments are not lingually inclined, then Propel need only be applied to the anterior dentition.(FIG 7) Within this proactive indication, there are several stark advantages that Propel has over other methods to accelerate tooth movement. Firstly, is a significantly lower overhead. Typically cases require one to two applications, hence only one to two tips or devices (about $100-$200) to deliver accelerated tooth movement rather than spending what the current market bears; about $1000 per device. Secondly, Propel allows doctors to be in control and target exactly where the movement needs to be facilitated rather than relying on patient
cooperation or affecting the whole mouth unnecessarily and in an uncontrolled fashion. In a sense, micro-osteoperforations, prepare the bone and tissues for orthodontic tooth movement. Depending on the quality of desired tooth movement, at minimum, patients can change their aligners weekly, to a maximum of every three to four days instead of the standard two weeks. The frequency of switching ultimately depends on the doctor’s judgment, as well, as the quality of movement that is being attempted. For instance, simple crowding without rotations requiring only in and out labial movement may be a candidate for switching every 3-4 days, while crowding with a significant rotation or axial root movement or intrusion of anterior teeth for deep overbite correction may be better titrated at weekly switches. It is up to the discretion of the doctor to decide what is best given the initial malocclusion and misalignment.
Delivery and Performing Propel There are publications discussing the use of profound topical anesthetics prior to performing osteoperforations. It is important for the private practitioner to understand all the particulars involved in using these. Alternatively, traditional infiltrative local anesthetic may be used. There are advantages and disadvantages
for each approach and it is imperative for the clinician to make themselves familiar with them prior to using them.11,12 Furthermore, protocol for sepsis control is well documented in the literature. Suffice it to say, it is very similar to placing TAD’s in that you have the patients rinse with chlorohexidine twice for one minute each time. When delivering osteoperforations in the lower arch, it is wise to ask the patient to bite with gentle, yet firm pressure. Some advocate having the patient bite into a warm wax bite as this may help them with the stabilization. This is important in helping stabilize the mandible rather than relying on the clinician to clutch and hold the jaw with their own hand. This proves uncomfortable for the patient since often times the clinician’s hand grips the mylohyoid both externally and internally. Experience has proven that there is less bobbing of the patient’s back and forth with this approach while doing osteoperforations. Secondly, with the patient biting down, this allows for maximum retraction of the cheek making access to the molars much easier as compared to when they are open and the cheek is taut. To deliver osteoperforations in the upper arch is easier as clinicians can stabilize the upper jaw using gentle finger pressure on the palate when perforating the buccal and labial surfaces. Again, asking the patient to slightly close will allow for more cheek retraction and easier access to the molar region.
The advent of Propel’s new Excellerator PT (Power Tip) delivers osteoperforations via an electric driver with precisely designed torque and rpm’s. The PT driver has proven that this is a smoother experience for both the patient and doctor. Anecdotally, both fixed and movable tissue response and recovery has been even more favorable than with the manually driven drivers. Moreover, doctors no longer experience hand and wrist fatigue that one might when first starting to perform osteoperforations with manually driven Propel drivers. Following rinsing with chlorohexidine, patients are dismissed with instructions to only take acetaminophen for any discomfort and to avoid asprin or NSAIDs as this will negate the inflammatory response we are trying to stimulate. They are next appointed to in twelve to fourteen weeks to repeat the process until the desired tooth movement is accomplished.
Concluding Remarks It might be said that the advent of an orthodontist’s ability to correct malocclusions with plastic aligners is as ‘shocking’ as it was for Ben Franklin to discover electricity with a key on a kite. Like Mr. Franklin’s curiosity of trying to harness and use electricity, orthodontists’ inquisitiveness of doing the same with
plastic as brackets has produced the possible out of what was once thought of as impossible. Smart partnering and application of controlled localized inflammation with aligner therapy is only a natural and logical “next step.” As mentioned at the onset of this article, while practitioners might, time will not delay and more so, lost time is never found again. Aligner therapy and the ability to augment a patient’s own biology in facilitating tooth movement are here, and are here to stay. It is in the clinician’s fervent interest to remain relevant with the changing industry landscape of evolving technologies. Like the application of controlled localized inflammation technology itself, doctors can chose to do so ‘proactively’ or ‘reactively’.
REFERENCES: 1. Tuncay O, Nicozisis J, Morton J: Chapter 12: The Invisalign system, 2014. Mosby’s Orthodontic Review Second Edition, English J. 2. Teixeira CC, Khoo E, Tran J, Chartres I, Liu Y, Thant LM, et al. (2010). Cytokine expression and accelerated tooth movement. J Dent Res 89:11351141
3. Alikhani M, Raptis M, Corpodian C, Barrera LM, Alansari S, Khoo E, Teixeira C. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013; 144(5): 639-648. 4. Nicozisis J.: Propel: the fourth order of orthodontics, Orthod. Pract. Vol 5, 3:24-28, 2014 5. Nicozisis J.: Propel: the fourth order of orthodontics, Orthod. Pract. Vol 5, 3:24-28, 2014 6. Nicozisis J: Aligners can for your cants, Aug. 2013: Orthod. products 7. Nicozisis J: Tripping the plastic fantastic, Nov. 2103 Orthod. products 8. Tuncay O, Paquette D, Nicozisis J: Summer reports and clinical techniques. 2006 9. Chumbley and Tuncay, 1986Chumbley, A.B., Tuncay, O. The effect of indomethacin on the rate of orthodontic tooth movement. Am. J. Orthod. 1986;89:312–314 10. Nicozisis J.: Tips and troubleshooting techniques for seamless invisalign delivery. Recorded Webinar Aligntech Institute.com, 2014 Invisalign Summit 11. Kravitz N, Graham J, Nicozisis J, Gill J (2015). Compounded Topical Anesthetics In Orthodontics. JCO Vol XLIX Num 6:307-313
12. Nicozisis J.: Topical anesthesia and patient messaging, Orthod. Pract. Vol 6, 1:24-25, 2015. FIGURE LEGENDS
Figure 1. A) Clinical appearance of tissue response at the time of the procedure, B) 30 minutes after the procedure.
Figure 2. An Example of a reactive approach. A) After three unsuccessful attempts with different sets of aligners to correction the rotation of #27, one treatment of Propel was used reactively in the third refinement to resolve the stubborn rotation. B) Three perforations were done on both the mesial and distal of the tooth for a total of six perforations in one office visit. It took less than twelve minutes from delivering anesthesia to completing the perforations. No follow up was necessary.
Figure 3A-E. An example of a targeted application: using a combination of partial fixed appliances, TAD’s, aligners and 4 treatments of Propel, these molars were uprighted in 12 months.
Figure 4. A) Before: Propel procedures were performed in 12 months from first molar to mesial of the lateral incisors in all four quadrants to correct posterior crossbite and ninety degree rotation of #20. B) After: One refinement was necessary and no elastics were used.
Figure 5A,B. An example of a targeted application. Treatment completed in 5.5 months with 2 Propel applications in the upper and lower anteriors, and the lower right quadrant. Invisalign and Class-III elastics on the right only were used. Targeting Propel in the lower right quadrant allowed for Class-III elastic forces to be more effective and efficient. Note: Propel done on the left side or the upper right buccal quadrant as these are not etiology of the subdivision Class-III occlusion.
Figure 6A,B. An example of a targeted application. Treatment was completed in 11 months with tw2 Propel applications in the upper and lower anterior and right quadrants only. Invisalign and Class-II elastics on the right side only were used. Targeting Propel in the right quadrants allowed for Class-II elastic forces to be more effective and efficient. Note: Propel done on the left side as these are not etiology of the subdivision Class-II occlusion.
Figure 7 A,B. An example of a proactive application. Treatment lasted 7 months with 2 Propel applications in the upper and lower anterior only. Invisalign with one refinement used.
www.elsevier.com/locate/ysodo
PII: DOI: Reference:
S1073-8746(16)30062-7 http://dx.doi.org/10.1053/j.sodo.2016.10.006 YSODO483
To appear in: Seminars in Orthodontics Cite this article as: Jonathan L. Nicozisis, Applications of controlled local inflammation in aligner treatment, Seminars in Orthodontics, http://dx.doi.org/10.1053/j.sodo.2016.10.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Applications of Controlled Local Inflammation in Aligner Treatment
Jonathan L. Nicozisis, DMD, MS Princeton Orthodontics Princeton Professional Park 601 Ewing St., B-12 Princeton, NJ 08540
[email protected]
Tel
(609) 924-3271
Fax
(609) 924-7098
‘You May Delay, But Time Will Not and Lost Time Is Never Found Again.’ –Benjamin Franklin.
INTRODUCTION It can no longer be argued aligner therapy is the lesser means to provide orthodontic treatment. To still deny it is tantamount to be the proverbial ostrich with its head in the sand. In order to stay relevant the private practitioner should
not hold this denial-driven mindset or procrastinate to embrace the evolving landscape of our orthodontic industry. As aligner therapy advances to make fixed appliances the minority of treatment modalities, clinician’s ability to advantageously augment host tissue response to orthodontic forces in an effort to facilitate tooth movement is also becoming common place 1. More so, the advent of micro-osteoperforations via Propel’s Excellerator technology helps prepare bone and tissue for orthodontic tooth movement. What was once thought of as science fiction has now transitioned into a reality in private practice. Modestly put, an increase in local inflammation via trans-mucosal osteoperforations (Propel Excellerating Technology) promotes osteoclastogenesis, osteoclast recruitment and differentiation. This causes the bone to remodel faster and hence teeth move faster through the bone 2. This process has been proven to be a safe and repeatable procedure that is well-tolerated and accepted by patients, who report minimal discomfort, when compared to orthodontic tooth movement alone 3. In combining aligner therapy with controlled localized inflammation, Propel-aided aligner treatment enables clinicians to proactively deliver better outcomes, in shorter treatment times or to reactively respond to resolve and
complete stubborn and challenging movements. Experience and evidence of either approach has evolved to make Propel-aided aligner treatment to be a valuable, double-edged tool in the clinician’s armamentarium. The scope of this paper is to convey such experience and evidence while attempting to suggest techniques for easy clinical adoption and delivery 4,5,6,7,8.
Brief review of science behind Propel’s Excellorating Technology Orthodontic tooth movement (OTM) is controlled trauma. As such, there is an inflammatory response that is elicited and necessary for OTM to occur. Research shows that without this inflammatory response OTM will not occur. More so, efforts to thwart it will also retard OTM 9. As previously stated, the micro-insults or micro-trauma caused by transmucosal osteo-perforations elicits a localized inflammatory response. It stimulates osteoclastogenesis, osteoclast recruitment, and differentiation. In turn, the bone remodels faster and temporarily becomes less dense. The net result is that the teeth move faster through the bone. There is no recovery time that is necessary following the procedure. There are no sutures to be removed at subsequent followup appointments that would necessitate taking more time off of work or school. There is no swelling that occurs in days following, and thus far, no reported cases
of infection following the procedure. It is a quick and safe procedure that is able to be performed in the clinic without disruption to the office schedule. Reported data suggest this stimulated inflammatory response peaks in 24-36 hours following the procedure and remains elevated only to return to pre-treatment levels 10-12 weeks subsequently. Furthermore, the inflammatory response radiates 6-10mm around each perforation 2. This is significant when it comes to deciding how many perforations to perform. If Propel is used reactively on one or two teeth, it would be beneficial to perform three perforations around (mesial and distal) these teeth to stimulate as much localized inflammation as possible. If, however, one is proactively perforating a whole quadrant, due to the radiating effect, experience has shown that two perforations are sufficient to elicit the desired enhanced bone remodeling response. Currently, there are clinical trials underway assessing the optimal number of perforations necessary to accomplish certain types of movement. At this time of this publication, however, the best practice protocol is described as above. It is necessary to go through the cortical plate of bone and into the medullary bone. Rather than ‘cutting’ the bone or ‘coring’ a sample from the bone, osteoperforations should be thought of as to ‘displace’ the medullary bone. As such, there is minimal physical trauma to both hard and soft tissues, bleeding, and recovery time following the procedure. There are no potential negative sequelae
such as swelling or infections as there can be with other surgical approaches that attempt to augment a patient’s own biological response during tooth movement. To explain the phenomenon by analogy, imagine a block of ice drilled with a handpiece. The ice would be cut and removed leaving a perfectly smooth path where the bur once was, and the remaining ice untouched or un-phased. If this were bone it would respond by a lot more bleeding and coagulation, and also a lot more necessary recovery time for the bone to heal, fill in, and return to homeostasis. In contrast, now imagine slowly twisting a threaded screw into the same block of ice. Rather than coring a hole into the ice like a drill bit, the threaded screw would instead cause radiating fractures in the block of ice. Clinically, this same process creates radiating fractures in the medullary bone. In effect, these radiating micro fractures elicit a larger amount of radiating inflammatory response with much less bleeding and recovery time, compared to boring a hole into the bone. It is this unique characteristic that makes osteoperforations with Propel’s Exelleration technology highly effective and unmatched. As such, patients can go about their daily routine following the procedure without any disruption other than the anesthesia wearing off. Any bleeding has stopped before patients leave the office.(FIG 1.)
Indications for Reactive Approaches for Propel-aided aligner treatment The obvious indications for the reactive approach are to close stubborn extraction spaces or to resolve rotations.(FIG 2) A single application of Propel may assist in resolving these challenges in one visit rather than take 2-3 visits to accomplish the same thing or it may replace the need for additional sets of refinement aligners. For the aligner patient, this means possibly avoiding an extra scan for refinement or additional aligners. It may also help roots track better as the bone is temporarily less dense to enhance the bodily movement. Less apparent indications are protraction of posterior teeth, cant correction of smile lines or occlusal planes, uprighting molars (FIG3), palatally erupting canines, and the like. The merits of using propel assisted aligner treatment in such specific clinical instances can be communicated to the patients by informing them it may reduce the number of office visits, and to complete the treatment or number of refinements by promoting better tracking of the teeth within the aligner. This, of course, is provided that the ClinCheck is designed correctly.
Indications for Proactive Approaches for Propel-aided aligner treatment: whole mouth vs segments depending on mechanics
The most impactful indication for using Propel is to accelerate treatment overall. For the patient the impact is realized with fewer and less frequent visits to the office to complete their treatment. Patients only need to go to the office every three to three and a half months to have the procedure performed and to be given more aligners. Again, this is provided that the ClinCheck is designed to ‘set it and forget it’ from the start.10 With this mindset, the clinician bonds all attachments from the start and keeps them to the end. All IPR is done prior to the scan if access allows, or at refinement after alignment and tissue reaction is assessed. In this fashion, doctors or staff need not open and review ClinChecks during office visits to keep track of what needs to be added or removed at which stage. This is disruptive to seamless integration and scheduling. It is inconvenient to patients.
The astute clinician must decide if the whole mouth needs to be affected or if a segmented approach is indicated. For example, if it is a Class 1 crowding case with lingually inclined buccal segments or posterior crossbites in adults then it would be best to affect all four quadrants going back to the bicuspids or even the molars.(FIG4) If, however, it is a subdivision Class -II or Class-III, then it is only necessary to apply Propel to the offending quadrants that need to be corrected. Another way
to think about it is to assess the etiology of the subdivision and what quadrant needs help in facilitating tooth movement for its correction. For example, in a subdivision Class-III where elastics alone are needed for correction, Propel only needs to be applied once or twice in the upper and lower anterior and only the lower right buccal quadrant. Such protocol will not only help facilitate the diastema space closure, but also help the elastic forces work more effectively on the right for midline and Class-III correction while the alveolar bone is temporarily softened.(FIG 5) Likewise, for a subdivision Class-II case, Propel need only be applied to the offending side to help facilitate elastic forces and tooth movement for better outcomes in faster times.(Fig 6) More so, if anterior crowding only need to be corrected and the buccal segments are not lingually inclined, then Propel need only be applied to the anterior dentition.(FIG 7) Within this proactive indication, there are several stark advantages that Propel has over other methods to accelerate tooth movement. Firstly, is a significantly lower overhead. Typically cases require one to two applications, hence only one to two tips or devices (about $100-$200) to deliver accelerated tooth movement rather than spending what the current market bears; about $1000 per device. Secondly, Propel allows doctors to be in control and target exactly where the movement needs to be facilitated rather than relying on patient
cooperation or affecting the whole mouth unnecessarily and in an uncontrolled fashion. In a sense, micro-osteoperforations, prepare the bone and tissues for orthodontic tooth movement. Depending on the quality of desired tooth movement, at minimum, patients can change their aligners weekly, to a maximum of every three to four days instead of the standard two weeks. The frequency of switching ultimately depends on the doctor’s judgment, as well, as the quality of movement that is being attempted. For instance, simple crowding without rotations requiring only in and out labial movement may be a candidate for switching every 3-4 days, while crowding with a significant rotation or axial root movement or intrusion of anterior teeth for deep overbite correction may be better titrated at weekly switches. It is up to the discretion of the doctor to decide what is best given the initial malocclusion and misalignment.
Delivery and Performing Propel There are publications discussing the use of profound topical anesthetics prior to performing osteoperforations. It is important for the private practitioner to understand all the particulars involved in using these. Alternatively, traditional infiltrative local anesthetic may be used. There are advantages and disadvantages
for each approach and it is imperative for the clinician to make themselves familiar with them prior to using them.11,12 Furthermore, protocol for sepsis control is well documented in the literature. Suffice it to say, it is very similar to placing TAD’s in that you have the patients rinse with chlorohexidine twice for one minute each time. When delivering osteoperforations in the lower arch, it is wise to ask the patient to bite with gentle, yet firm pressure. Some advocate having the patient bite into a warm wax bite as this may help them with the stabilization. This is important in helping stabilize the mandible rather than relying on the clinician to clutch and hold the jaw with their own hand. This proves uncomfortable for the patient since often times the clinician’s hand grips the mylohyoid both externally and internally. Experience has proven that there is less bobbing of the patient’s back and forth with this approach while doing osteoperforations. Secondly, with the patient biting down, this allows for maximum retraction of the cheek making access to the molars much easier as compared to when they are open and the cheek is taut. To deliver osteoperforations in the upper arch is easier as clinicians can stabilize the upper jaw using gentle finger pressure on the palate when perforating the buccal and labial surfaces. Again, asking the patient to slightly close will allow for more cheek retraction and easier access to the molar region.
The advent of Propel’s new Excellerator PT (Power Tip) delivers osteoperforations via an electric driver with precisely designed torque and rpm’s. The PT driver has proven that this is a smoother experience for both the patient and doctor. Anecdotally, both fixed and movable tissue response and recovery has been even more favorable than with the manually driven drivers. Moreover, doctors no longer experience hand and wrist fatigue that one might when first starting to perform osteoperforations with manually driven Propel drivers. Following rinsing with chlorohexidine, patients are dismissed with instructions to only take acetaminophen for any discomfort and to avoid asprin or NSAIDs as this will negate the inflammatory response we are trying to stimulate. They are next appointed to in twelve to fourteen weeks to repeat the process until the desired tooth movement is accomplished.
Concluding Remarks It might be said that the advent of an orthodontist’s ability to correct malocclusions with plastic aligners is as ‘shocking’ as it was for Ben Franklin to discover electricity with a key on a kite. Like Mr. Franklin’s curiosity of trying to harness and use electricity, orthodontists’ inquisitiveness of doing the same with
plastic as brackets has produced the possible out of what was once thought of as impossible. Smart partnering and application of controlled localized inflammation with aligner therapy is only a natural and logical “next step.” As mentioned at the onset of this article, while practitioners might, time will not delay and more so, lost time is never found again. Aligner therapy and the ability to augment a patient’s own biology in facilitating tooth movement are here, and are here to stay. It is in the clinician’s fervent interest to remain relevant with the changing industry landscape of evolving technologies. Like the application of controlled localized inflammation technology itself, doctors can chose to do so ‘proactively’ or ‘reactively’.
REFERENCES: 1. Tuncay O, Nicozisis J, Morton J: Chapter 12: The Invisalign system, 2014. Mosby’s Orthodontic Review Second Edition, English J. 2. Teixeira CC, Khoo E, Tran J, Chartres I, Liu Y, Thant LM, et al. (2010). Cytokine expression and accelerated tooth movement. J Dent Res 89:11351141
3. Alikhani M, Raptis M, Corpodian C, Barrera LM, Alansari S, Khoo E, Teixeira C. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013; 144(5): 639-648. 4. Nicozisis J.: Propel: the fourth order of orthodontics, Orthod. Pract. Vol 5, 3:24-28, 2014 5. Nicozisis J.: Propel: the fourth order of orthodontics, Orthod. Pract. Vol 5, 3:24-28, 2014 6. Nicozisis J: Aligners can for your cants, Aug. 2013: Orthod. products 7. Nicozisis J: Tripping the plastic fantastic, Nov. 2103 Orthod. products 8. Tuncay O, Paquette D, Nicozisis J: Summer reports and clinical techniques. 2006 9. Chumbley and Tuncay, 1986Chumbley, A.B., Tuncay, O. The effect of indomethacin on the rate of orthodontic tooth movement. Am. J. Orthod. 1986;89:312–314 10. Nicozisis J.: Tips and troubleshooting techniques for seamless invisalign delivery. Recorded Webinar Aligntech Institute.com, 2014 Invisalign Summit 11. Kravitz N, Graham J, Nicozisis J, Gill J (2015). Compounded Topical Anesthetics In Orthodontics. JCO Vol XLIX Num 6:307-313
12. Nicozisis J.: Topical anesthesia and patient messaging, Orthod. Pract. Vol 6, 1:24-25, 2015. FIGURE LEGENDS
Figure 1. A) Clinical appearance of tissue response at the time of the procedure, B) 30 minutes after the procedure.
Figure 2. An Example of a reactive approach. A) After three unsuccessful attempts with different sets of aligners to correction the rotation of #27, one treatment of Propel was used reactively in the third refinement to resolve the stubborn rotation. B) Three perforations were done on both the mesial and distal of the tooth for a total of six perforations in one office visit. It took less than twelve minutes from delivering anesthesia to completing the perforations. No follow up was necessary.
Figure 3A-E. An example of a targeted application: using a combination of partial fixed appliances, TAD’s, aligners and 4 treatments of Propel, these molars were uprighted in 12 months.
Figure 4. A) Before: Propel procedures were performed in 12 months from first molar to mesial of the lateral incisors in all four quadrants to correct posterior crossbite and ninety degree rotation of #20. B) After: One refinement was necessary and no elastics were used.
Figure 5A,B. An example of a targeted application. Treatment completed in 5.5 months with 2 Propel applications in the upper and lower anteriors, and the lower right quadrant. Invisalign and Class-III elastics on the right only were used. Targeting Propel in the lower right quadrant allowed for Class-III elastic forces to be more effective and efficient. Note: Propel done on the left side or the upper right buccal quadrant as these are not etiology of the subdivision Class-III occlusion.
Figure 6A,B. An example of a targeted application. Treatment was completed in 11 months with tw2 Propel applications in the upper and lower anterior and right quadrants only. Invisalign and Class-II elastics on the right side only were used. Targeting Propel in the right quadrants allowed for Class-II elastic forces to be more effective and efficient. Note: Propel done on the left side as these are not etiology of the subdivision Class-II occlusion.
Figure 7 A,B. An example of a proactive application. Treatment lasted 7 months with 2 Propel applications in the upper and lower anterior only. Invisalign with one refinement used.