58 dentaltownJune 2004

Guest Editorial

Life is full of choices. When a patient comes to your office want-ing a nicer smile our choices have traditionally been a porcelainveneer smile, makeover or comprehensive two-year orthodontictreatment. Many patients object to the removal of facial enamel tofacilitate veneer placement and many patients will not wear bracesfor two years. So what can you do? Now you can offer a new alter-native: The Powerprox Six Month Braces™ Technique (PPSMB).

The goal of porcelain veneers is to give your patient a greatsmile, the goal of PPSMB is the same, only instead of preparingteeth and bonding porcelain we move the teeth to their most beau-tiful position. This allows for a more conservative treatment optionfor many types of cases including, but not limited to; crowding,spacing, crossbites, deep bites, and open bites (Fig. 1).

Many times we will use PPSMB prior to placing veneers to geta nicer result than we could by using either alone. How many of ushave had that nearly impossible veneer case walk through the doorwhere we knew if we could get some tooth movement it wouldgreatly simplify the cosmetics? We all have. By correcting thecrowding, lining up the teeth, and opening the bite first; we canreduce the amount of tooth reduction required for our veneers,reduce or eliminate the need for intentional endodontics, and min-imize the amount of anterior crown lengthening needed to perfectthose cosmetic cases. Simply stated the PPSMB makes those impos-sible veneer cases easy (Fig. 2).

Rick DePaul, Jr., DDSPresident, Six Month Braces, LLC

The Powerprox Six MonthBraces™ Technique

Figures 1a and 1bIn this case wecorrected theirrotations andcrowding andgave the patient a great smile injust over sevenmonths.

Figures 2a and 2bA combination of

PPSMB, cosmetic and

restorative dentistry made his impossible

case easy.

1a

1b

2a

2b

ReproximationMany feel crowding is caused by the continual reduction of jaw

size in human evolutionary development. Whatever the cause,crowding is a discrepancy between the mesiodistal size of the teethand the length of the dental arch. It stands to reason, if there is away to reduce the mesiodistal width of the teeth, you can alleviatecrowding in the arch. With PPSMB we gain space locally primarilyby interproximal polishing, also known as stripping, or enamelreproximation, or reprox for short. Space is created locally, where itis needed, and the teeth are gently aligned into the newly createdspace. The use of reprox has been well documented, but we feel weare using it in a new and exciting way to achieve our dramaticresults. Reprox is a time-tested technique in orthodontics. Ballardfirst described Reprox in 1944. Reprox is one of the most conserva-tive methods available to alleviate crowding. In addition to creatingspace, reprox flattens the contact areas, which increase the stabilityof the final result. This helps minimize relapse after treatment.Reprox can be performed at any time during the treatment, when-ever more space is needed. There are many ways to perform reprox,including diamond strips, or diamond and carbide burs. We havefound the most rapid and effective way to reprox is to begin with adiamond disk followed by smoothing with a finishing bur. A dia-mond strip, or interproximal finishing strip, can be used for finalfinishing of the interproximal enamel, if desired. This methodquickly creates space and smooth edges with no pain to the patient.The only exception to this rule is on rotated teeth where the use ofa disk would affect the facial or lingual surface of the teeth. We usea bur and/or a diamond strip in these instances since we want inter-proximal reduction only. In effect we are “shrinking teeth”mesiodistally in order to align them to their appropriate position. Inaddition to creating space, reprox also reduces the friction betweentooth contacts; this reduces the amount of force the archwire mustovercome, allowing for quicker tooth movement. After reprox iscompleted a fluoride treatment can be given if desired. The dia-mond disk we currently use for reprox is a: Brasseler #934-220 Lite.It has a thickness of .15 millimeters (Figs. 4 and 5).

The question we are often asked is: How much enamel can yousafely remove? Sheridan suggested that 50% of the interproximalenamel could be reduced. Proffit says the teeth can be reduced up to0.5mm on each side without reaching the dentin. We have found thatoften you can reprox more than 0.5mm, especially on wide teeth,with no adverse effects. A significant amount of space can be gainedby reprox. For example, if you reprox all the contacts from the distalof #6 to the distal of #11 you can often gain up to 7mm of space. Thisis usually more than enough to correct most crowded cases.

Although we will reprox anywhere we need space, it seems weshould reprox where the enamel is thickest. On the upper anteriorteeth, the thickest enamel is on the mesial and distal of the caninesand the distal surfaces of the central incisors. On the lower anteriorteeth, the thickest enamel is on the mesial and distal surfaces of thecanines and the distal surfaces of the lateral incisors. Many doctorsare concerned that the thinning of enamel will increase the patient’ssusceptibility to tooth decay and periodontal disease. In actuality,investigators have reported no increase in either caries or periodon-tal disease due to a reduced enamel surface. Sheridan stated that nostudy indicated how much enamel is needed for adequate protectionof the teeth. The natural variation in thickness of enamel suggeststhat there is no protective advantage in preserving thick interproxi-mal enamel when thin enamel occurs naturally on the facial and lin-gual surfaces of the teeth. Certain studies did show some increasedroughness of reproxed enamel when compared to virgin enamel, butthere was no increase in decay. In one study El-Mangoury indicatedthat reprox did not expose enamel to changes that caused caries.There was a period of demineralization followed by remineralizationwithin nine months. Some have suggested placing a sealant afterreprox, but this would actually interfere with the constant reminer-alization that naturally occurs. However, a fluoride treatment can begiven after reprox. Craine and Sheridan also demonstrated reproxedteeth are no more susceptible to caries or periodontal disease thanunaltered surfaces. When done properly reprox has no negativeeffects on the bone or interproximal tissue. Tuverson reported a neg-ligible periodontal change and showed gingival papillae that wereactually greatly improved after correction of crowding with reprox.In a nine year study Boese found no significant increase in pocketdepth, gingival recession or loss of alveolar bone.

59dentaltownJune 2004

Guest Editorial

Reprox and Nickel Titanium Archwires:A Powerful Combination.The number one complaint patients have is crowding. Inorder to correct the crowding we often use a combinationof reprox and nickel titanium archwires. These two worksynergistically together to correct even very severelycrowded teeth. (Figure 3)

Figures 3a and 3bThe powerful combination of reprox and nickel titaniumgave us this result in less than three months treatment time.

3a 3b

4

5

Figure 4You can see how perfectly a dia-

mond disk fits between theteeth. This is an ideal instru-

ment for reprox. You simplydisk through the contact point,making sure to go all the way

down to the gingiva. Then pol-ish with a finishing bur and a

polishing strip.

Figure 5Here is the net result. You can

see the amount of enamelremoved is quite small, but itcreates enough space to allevi-ate the crowding. More reprox

can be preformed at subse-quent appointments as needed.

Continued on page 60

60

Guest Editorial

dentaltownJune 2004

Continued from page 59

Nickel Titanium ArchwiresNickel titanium archwires are critical to the success of PPSMB

due to their shape memory, high flexibility and the consistent sus-tained forces they put on the teeth. All of these properties allow forthe ligation of severely malposed teeth and allow them to be gentlymoved to the desired position quickly and safely (Fig. 6). Nickeltitanium archwires are the perfect combination of strength and flex-ibility (Fig. 7). The main tooth movements used in the PPSMB aretipping, rotations, intrusion, extrusion, with some translation andtorquing. Nickel titanium wires are more than adequate to accom-plish these movements. Conclusion

Remember the goal of PPSMB is to give your patients a greatsmile. No matter what type of malocclusion the patient has, thegoal is always the same. Give your patient a great smile. As suchPPSMB can be use on a variety of different case types such as

Figure 6This picture shows theincredible flexibility of

nickel titanium archwires.Even with severe rotationswe were able to get com-plete bracket engagementby using nickel titanium

archwires.6

Figure 7a and 7 bThe strength and flexi-

bility of nickel titaniumcoupled with reprox

allowed for this dramat-ic progress in less than

three months.

7b

7a

Remember the goalof PPSMB is to give

your patients agreat smile.

Continued on page 62

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62 dentaltownJune 2004

Guest EditorialContinued from page 60

Bibliography:Ballard ML. Asymmetry in tooth size: A factor in etiology diagnosis, and treat-ment of malocclusion. Angle Orthod 1944;14:67-70.Sheridan JJ. Air-rotor stripping update. J Clin Orthod 1985;19:43-59.Sheridan JJ. Air-rotor stripping update. J Clin Orthod 1987;21:781-88.Proffit WR. Contemporary Orthodontics. Missouri: CV Mosby, 1986.Peck H, Peck S. Reproximation (enamel stripping) as an essential orthodontictreatment ingredient. C.V. Mosby Co., St Louis, 1975, pp. 513-522.

El-Mangoury NH, Moussa MM, Mostafa YA, Girgin AS. In-vivo remineral-ization after air-rotor stripping. J Clin Orthod 1991;25:75-78.Craine G, Sheridan JJ. Suceptibility to caries and periodontal disease after pos-terior air-rotor stripping. J Clin Orthod 1990;4:84-5.Tuverson DL. Anterior interocclusal relations: Part 1. Am J Orthod1980;78:361-70.Boese LR. Fiberotomy and reproximation without lower retention: Nine yearsin retrospect. Angle Orthod 1980;50;88-97, 169-178.

crowding, spacing, crossbites, deep bites, and open bites (Figs. 8and 9).The use of reprox and nickel titanium archwires are just twoof the “pieces of the PPSMB puzzle” that we use to give patients thesmiles they have always wanted in such a short period of time. Thedemand for this service is astronomical. Personally, we have treatedpatients who have driven or flown in from 8 different states to getPPSMB. We had one patient who actually had her phone discon-nected to pay for PPSMB. She could not afford both so she optedto straighten her teeth and improve her smile. This shows the levelof dedication and motivation present for PPSMB.

Now you have a choice to make. In addition to providing porce-lain veneers and comprehensive two-year orthodontics, hopefullyyou will also offer PPSMB. It is one more “tool in your belt” to helpyour patients reach their cosmetic goals.

Richard J. DePaul, Jr., DDS graduated in 1994 from Case WesternReserve University. He is the author of the book “The Powerprox SixMonth Braces Technique. The Next Step in the Cosmetic DentistryRevolution.”

Figure 8a and 8bDivision 2 cases can also be treated with PPSMB.

8a 8b

Figure 9a and 9bThis challenging open bite case was completed in just seven monthsusing PPSMB.

9a 9b

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