Digital Planning and Custom Orthodontic Treatment

Digital Planning and CustomOrthodontic Treatment

Edited by

Dr. K. Hero BreuningOrthodontist and Consultant

Prof. Chung H. KauUniversity of Alabama, Birmingham, AL, USA

This edition first published 2017.© 2017 John Wiley & Sons, Inc.

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Library of Congress Cataloging-in-Publication Data

Names: Breuning, K. Hero, editor. | Kau, Chung How, editor.Title: Digital planning and custom orthodontic treatment / edited by K. Hero Breuning, Chung H. Kau.Description: Hoboken, NJ : John Wiley & Sons Inc., 2017. | Includes index.Identifiers: LCCN 2016053363| ISBN 9781119087779 (pbk.) | ISBN 9781119087786 (Adobe PDF) | ISBN

9781119087793 (ePub)Subjects: | MESH: Dental Impression Technique–instrumentation | Cone-Beam Computed Tomography–methods

| Radiography, Dental, Digital–instrumentationClassification: LCC RK521 | NLM WU 25 | DDC 617.6/43–dc23 LC record available at

https://lccn.loc.gov/2016053363

Set in 10/12pt WarnockPro by Aptara Inc., New Delhi, India

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v

Contents

List of Contributors viiPreface xiAcknowledgments xv

Documentation of the Dentition 1K. Hero Breuning

Documentation of the Face 9K. Hero Breuning

Dynamic Motion Capture of the Mandible 15Shushu He and Chung H. Kau

Analysis of Digital Dental Documentation 27K. Hero Breuning and Chung H. Kau

Orthodontic Treatment Planning 31K. Hero Breuning and Chung H. Kau

Custom Appliance Design 41K. Hero Breuning

Custom Appliance Fabrication and Transfer 47K. Hero Breuning

Monitoring of Tooth Movement 55Philippe Salah and K. Hero Breuning

Custom Retention after Orthodontic Treatment 65K. Hero Breuning

The Invisalign System 69Orhan Tuncay

vi Contents

Custom Lingual Appliances 81Neil Warshawsky, Thomas W. Ortendahl, Chung H. Kau and K. Hero Breuning

Appendix 115

Index 117

vii

List of Contributors

K. Hero Breuning DDS, PhD K. Hero Breuning studied dentistry and orthodontics atthe University of Utrecht, the Netherlands and starteda private orthodontic office in Tiel, the Netherlands.He worked closely together with maxillofacial surgeonsand finished his PhD study on intraoral mandibular dis-traction at the Free University in Amsterdam. He was anassistant professor of 3D imaging at the Radboud Uni-versity in Nijmegen, department of Orthodontics andCraniofacial Biology. He has published over 60 jour-nal articles, lectured at major orthodontic meetings,and presented courses on various topics in 16 coun-tries. He is a reviewer for several orthodontic journals.Currently he is a lecturer, researcher, consultant, andtrainer in orthodontic offices. He loves his wife, chil-dren, and grandchildren and likes art, playing golf, ski-ing, and sailing.

Shushu He BDS, DDS, PhD Shushu He studied at the West China School of Stom-atology, Sichuan University, China and followed thePostgraduate program in Orthodontics at the SichuanUniversity, China. She was awarded as an Outstandingdental student and PhD student of Sichuan Univer-sity and she was a visiting scholar at the University ofAlabama at Birmingham, Alabama, USA. Currently sheis a lecturer, at the State Key Laboratory of Oral Disease,Department of Orthodontics, West China School ofStomatology, Sichuan University, China. Shushu pub-lished several articles in peer-reviewed journals.

viii List of Contributors

Chung H. Kau BDS, MScD, MBA,PhD, MOrth, FAMS, FDSGlas, FFD(Ortho), FDSEdin, FAMS, FICD

Chung H. Kau is Chairman and Professor at theDepartment of Orthodontics, University of Alabama atBirmingham, Alabama, USA. He is a Diplomate of theAmerican Board of Orthodontics and enjoys practicingclinical orthodontics. He has a keen interest in three-dimensional and translational research. At present he isPrincipal Investigator on a number of grants and has aresearch involvement in excess of $3.2 million dollars.He actively contributes and publishes in the orthodon-tic literature and has over 300 peer-reviewed publi-cations, conference papers, and lectures. He was alsomade the King James IV Professor by the Royal Collegeof Surgeons in Edinburgh in 2011.

Thomas W. ¨Ortendahl DDS Thomas W. ¨Ortendahl is a member of the SwedishOrthodontic Society, European Society, American Lin-gual Orthodontic Society, and the World Society ofLingual Orthodontics. He finished his dental train-ing in 1983 at the University of Gothenburg, Sweden.In 1987, he finished his PhD studies and started hisorthodontic training, which he completed in 1991.Since 1997, he has lectured worldwide on topics suchas Esthetic Orthodontic treatment. He was a clinicalinstructor at the University of Gothenburg for 10 years.Dr. ¨Ortendahl is co-author of the book Lingual andEsthetic Orthodontics (Quintessence Publishing, 2011)and is an adviser of several R & D departments. He isthe head Orthodontist at the Smile Group, Molndal,Sweden.

Philippe Salah PhD Philippe Salah graduated from Ecole Polytechnique,Palaiseau, France with a PhD in Biophysics, and madeorthodontics his favored research subject early in hiscareer. In 2007, he co-founded the Harmony system,the first fully customized self-ligating lingual solution.Acquired in 2011 by American Orthodontics, Harmonyexperienced remarkable international growth. In 2013,animated by a passion for optimization and deep learn-ing algorithms, he founded Dental Monitoring witha team of doctors, researchers, and engineers. DentalMonitoring is the world’s first web and mobile appli-cation designed for self-monitoring dental treatment.It provides doctors with a live vision of their patient’streatment evolution that includes a very accurate 3Dpositioning of the teeth and effective communicationand encouragement tools.

List of Contributors ix

Orhan Tuncay DMD Philadelphia orthodontist Orhan Tuncay is an iconin the world of orthodontics. His academic careeras an orthodontist is distinguished by his many con-tributions, innovations, and advances in the field oforthodontics. He has served as a department chairmanfor over 30 years and educated hundreds of orthodon-tists in the USA and abroad. His career started inthe Department of Biochemistry at the University ofPennsylvania School of Dental Medicine. Subsequently,he received his orthodontic training at the same insti-tution. He is known for his work on the biology oftooth movement, meta analyses, facial aesthetics, and3D imaging and animation of the human face. He holdspatents for his innovations in the field of 3D imaging. Hehas held innumerable official positions as an orthodon-tist in both scientific and professional organizationsincluding: Chairman of the Council on Scientific Affairsof the American Association of Orthodontists, Presi-dent of Greater Philadelphia Society of Orthodontists,and President of Craniofacial Biology Group of Interna-tional & American Association for Dental Research. Histextbook The Invisalign® System (Quintessence Pub-lishing, 2006) is the first textbook in the world onInvisalign. Additionally, he is the founding editor of fourinternational journals.

Neil Warshawsky DDS, MS Neil Warshawsky is the founder and owner of GetIt Straight Orthodontics, a leading orthodontic net-work in the Chicago area. A double board certifiedorthodontic specialist since 1992, he has over 23 yearsof experience with cleft palate and craniofacial cases.Currently, he is an Associate Professor of Surgery atthe University of Illinois Craniofacial Center. In his pri-vate practice, he concentrates on esthetics and is one oflargest volume users of IncognitoTM lingual braces in theUSA. He teaches advanced mechanical courses for 3MOral Healthcare in North America as well as hands-oncourses for Dentsply Raintree Essix around the worldon Essix appliance fabrication and design. When he isnot at work, he is an assistant scoutmaster for his sons’boy scout troop, at home with his high-school sweet-heart, fishing at the family cabin with one of their threekids, or just out for a run.

xi

Preface

The innovations in the documentation,analysis of a dental malocclusion, treat-ment planning, design, and fabrication oforthodontic appliances in the last decadehave been major. The traditional method todocument an orthodontic case with a plastercast and two-dimensional (2D) images, andtreat the patient with a selection of standardorthodontic brackets, after manual bracketplacement with a set of standard and manu-ally bended orthodontic wires, will not lead tothe most efficient and controlled orthodon-tic treatment. Traditional appliances andmechanics will need more treatment timeand the treatment result depends on the indi-vidual skills of the orthodontist. Currently,an orthodontist can use three-dimensional(3D) images for each patient who needsorthodontic and/or surgical treatment.Imaging of the dentition, skeleton, and theface in three dimensions allows a treatmentplan to be made in 3D, and computer-aideddesign (CAD) and computer-aided man-ufacturing (CAM) to make customizedorthodontic appliances (custom brackets,customized or custom aligners) to be usedfor the orthodontic treatment. If these cus-tom appliances are used, increased efficiencyand control during orthodontic treatmentcan be expected. CAD/CAM procedurescan replace the “art” of bracket selection,bracket positioning, and manual wirebending.

Patients now demand to see and dis-cuss diagnostic setups of the dentition and

the prediction of facial changes causedby orthodontic and maxillofacial treatmentbefore the start of treatment. They also wishto be treated in less time, with less visibleappliances without the need for extensivecooperation during treatment. They shouldget relevant information from the monitor-ing of the speed of tooth movement into theplanned direction during treatment. If toothmovement does not proceed as planned(because of appliance failures or inefficientmechanics), an alert should be sent to boththe orthodontist and the patient. If skele-tal correction during orthodontic treatmentis indicated, this surgery should be an inte-grated part of the treatment planning and theactual treatment.

Virtual treatment planning in 3D of boththe dentition and the skeletal changes willallow prediction of the facial changes aftertreatment. Because accurate dental and vir-tual surgical planning is now possible, eventhe amount of tooth movement neededbefore and after surgery can be predicted andevaluated

If required, maxillofacial surgery can beperformed at an earlier time during orthodo-ntic treatment, probably even after the ini-tial correction of the dentition. Early surgicalcorrection (“surgery first”) can be indicatedto correct the facial aesthetics and oral func-tions of the patient as soon as possible.Because virtual planning on 3D images witha 1 : 1 ratio is used, maxillofacial surgery canbe more predictable and controlled.

xii Preface

The orthodontist and maxillofacial sur-geon could send the 3D documentation andtreatment plan to a dental or surgical labfor segmentation of the dentition and partsof the skull to make an initial setup. Aftersegmentation of the dentition, the dental labtechnician can make an initial simulation ofthe treatment planned by the dental special-ist or maxillofacial surgeon. But the dentalprofessional or maxillofacial surgeon can alsoperform this segmentation process and sim-ulation (setup) in their own office with dedi-cated software programs. If the lab has madethe initial setup, an orthodontist needs tomake a definitive setup with CAD/CAM soft-ware. Before the introduction of the plannedtreatment and alternatives for this treatment,a setup can be discussed with other dentalprofessionals.

Digital documentation in 3D with a ratio of1 : 1 and digital dental and skeletal setups arerequired to design and fabricate orthodonticand surgical appliances. Introduction of theactual situation and the planned treatmentwith the use of a “virtual head” will be themost reliable way to show and discuss theplanned treatment with the patient.

After acceptance of the treatment plan andits costs, custom orthodontic and surgicalappliances used for this treatment can bedesigned. Removable appliances, fixed appli-ances and a set of aligners or a combination ofthese appliances can be used for orthodontictreatment. Usually, a dental lab will designthe selected appliance systems (CAD). Theorthodontist should approve the design ofthe appliances (e.g. the bracket positionor the position of the attachments foraligner treatment), and then these appliances(including a set of custom bend arch wiresfor fixed appliance treatment) should befabricated for effective and controlled toothmovement. For transfer of the plannedbracket or attachment position on the finalsetup to the actual dentition of the patient,indirect bonding procedures are needed.Because patients ask to reduce treatment

time with fixed appliances, treatment can bestarted with fixed custom orthodontic appli-ance systems and finished with clear aligners.

This “hybrid” orthodontic treatment app-roach (orthodontic treatment with a combi-nation of appliances) will be the treatmentof choice in the near future. Only increasedcontrol of all treatment procedures and themonitoring of treatment changes will enabletreatment of an increasing amount of patientsin a more predictable, more effective waywithout reduction of the quality of the treat-ment outcome. Both patients and referringdentists will appreciate the planning of thedental and surgical treatment on a virtualhead and will love to see the prediction of thedental and facial outcome before the start oftreatment.

The monitoring of tooth movement withintra-oral scans and intra-oral pictures takenat planned intervals will allow the plannedtreatment to be planned and optimized.

In this book, an overview of new develop-ments in orthodontics—with an emphasison 3D imaging, the digital planning oftreatment, the CAD/CAM fabrication ofappliances, and the monitoring of treatmentduring and after treatment—will be pre-sented. The workflow for several customappliance systems (Invisalign, Incognito,Harmony, Insignia, eBrace/eLock, andsuresmile) will be introduced by experiencedusers of these systems. Recent improvementsof custom systems will be presented in eachchapter.

The content of this book will change in theyears to come, so there will be a need for anupdate of the published information in thefuture.

For a full list of the companies who havekindly allowed us to use their images, pleasesee the appendix at the back of the book.

The book’s eleven chapters reflect apatient’s workflow:

Chapter 1: Documentation of the DentitionChapter 2: Documentation of the Face