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Ortho Tribune Middle East & Africa No.1, 2017

ÿPageE3 © 2016 Ormco Corporation Order your Damon Clear2 brackets today! Visit ormcoeurope.com Clear Performance. MoreControl. Offering the same crystal clear performance with more control,DamonClear2allowsyoutotreatawidevariety of cases with outstanding results so your practice and your patients can put their best face forward. *Variable torques for upper 3-3 brackets. **As compared to Damon Clear upper 3-3 brackets. Variable Torques* NEW! Actual Damon patients wearing Damon Clear. Treated by Dr. Todd Bovenizer. 100% CLEAR BRACKET BODY AND SLIDE for the supreme aesthetics patients demand SMOOTH, ROUNDED CORNERS for outstanding patient comfort INNOVATIVE SPINTEK™ SLIDE for easy and comfortable wire changes SELF-LIGATING BRACKET DESIGN eliminates the need for elastomerics which stain and collect bacteria FOUR SOLID WALLS with improved precision slot for 2x the rotational control** for meticulous finishing and efficient treatment A new era in digital orthodontics ByJeffreyT.Kozlowski,USA A true straight-wire appliance would necessitatepatient-specificapplianc- esbasedonanindividual’sanatomy. Now, with advances in computer software and digital scanning and fabrication, that idea is a reality and a practical consideration for your practice. Customized Insignia™ is the first true straight-wire appliance. It involves two components: cus- tomized appliances—brackets, wires and placement gauges—and 3D real-time virtual treatment planning software. The 3D software enables clinicianstodesignthepatient’sfinal occlusion on-screen before initiating treatment, then prescribes the fabri- cation of patient-specific appliances to achieve the planned result. This concept is quite different from how clinicians customarily practice or- thodontics. Traditionally, we choose appliances with specific torque val- ues to have certain effects, then re- act to those effects by repositioning brackets and making wire bends to guide the teeth into the desired po- sitions. With Insignia, we begin with theendinsightanddrivedirectlyto- wardsthedesiredendresult. Over 20 years in development, cus- tomized Insignia appliances offer the only comprehensive patient- specific solution available. The treat- ment planning process begins with accurate PVS impressions. New clinicalmethodsandmaterialsmake this procedure quick and easy. From the impressions, the pretreatment malocclusion (T1) is digitized into a precise mathematical model of the patient’s skeletal and dental anato- my and the proposed setup (T2) de- signed(Fig.1a-b). See Dr. Craig Andreiko’s discussion. The setup is loaded to the Insignia web portal where, ased on clinical experience, functional and esthetic preferences and intimate knowledge of the patient’s specific orthodontic needs, the clinician can easily cus- tomize it using the Insignia Approv- er software(Fig. 2). Theincluded soft- wareofferscliniciansunprecedented control in determining accurate tooth position and in their ability to make changes directly to the 3D models without relying on an opera- tor’sinterpretationofinstructions. Insignia does not determine treat- ment mechanics nor prescribe tooth movements and it allows clinicians tousethemechanicsandadjunctsof their choice. As doctors modify the desiredfinaloutcomeintheApprov- er software, they can view in “real time” how the changes affect the op- posing occlusion. Once the clinician finalizes the ideal setup, the Insignia software engineers the customized brackets, wires and precision bond- ing placement gauges to the exact prescription required to deliver the designed end result accurately and efficiently. My experience with Insignia is with both the customized passive self- ligating appliance (Insignia custom SL)andInsigniausingstockDamon® Systemappliances.TheInsigniasoft- warecanbeusedtofabricatepatient- specific conventional twin brackets and aligners as well. You can also use Insignia software with stock appli- ances (Orthos®, Inspire ICE™ and, as Imentioned,Damon). The difference between customized Insignia and Insignia using stock brackets is the third-order customi- zation (torque) that is engineered into the customized brackets. This difference saves considerable treat- ment time and effort over using a “best fit torque” stock appliance. Having treated with both custom- ized Insignia SL and Insignia using stock Damon brackets, I can attest to thesuperiorvalueofthecustomized appliances. TheClinicalEvaluation My initial experience with custom- ized Insignia SL began in 2007 when I conducted an extensive clinical evaluation by treating 41 patients to completion. The only limitations on the selection criteria were that patients have no missing or im- pacted teeth, no pending restorative needs, and must not exhibit poor oral hygiene. The criteria were lim- ited in these ways simply because it wouldn’t have been feasible for me to coordinate the ancillary pro- cedures from across the country. At the time, I was in the process of opening my new office in Connecti- cut and the clinical evaluation was to be conducted at Ormco in Califor- nia—nearly 3000 miles away. For operator consistency, I played the roles of doctor and assistant, per- forming the diagnoses, treatment planning, initial bondings and wire changes, providing all mechanics for 100%oftreatment.Fullrecordswere taken of each patient, including PVS impressions and iCAT® scans (Imag- ing Sciences, International, Hatfield, PA) for diagnostics and treatment planning using the Insignia interac- tiveApproversoftware.Basedonmy previous experience with Damon System appliances, I estimated that treatment time for the 41 patients wouldaverage17.5months. While I wouldn’t recommend select- ingthismanypatientstobegintreat- ing with customized Insignia SL for the first time, I am convinced that the best way to learn Insignia is to submit cases regularly. Regular case submission allows the clinician to relate what is designed in the digital environment to the clinical experi- ence and final results. This positive feedback loop of learning will help the clinician design each successive Insignia case with a higher level of understanding and accuracy and hence be more successful with its application. My experience has been that clinicians who regularly submit Insignia cases are more suc- cessful with it than those who start only a few cases and wait to see how they work out. My skills improved substantially through the first 10 to 20 cases, and like using any other new appliance, it takes a bit of time to learn the nuances. I also strongly recommend doctors initially select easiercases,andthenaddmorechal- lenging cases when they become fa- miliar with the software and clinical protocols. In late February, 2008, in a one-chair operatory at Ormco’s Insignia man- ufacturing facility in Glendora, Cali- fornia, I bonded all 41 patients over a five-day period. This intensive week of bonding proved to be my first in- sight into the potential efficiencies of Insignia’s direct view/indirect bonding process. After just the first few patients my bonding technique using the placement gauges sig- nificantly improved and during the balance of the week, the bonding ap- pointments averaged less than one hour, including preparing the teeth, bonding the brackets, placing bite turbos, engaging the wires, attach- ing the elastics and reviewing the patient instructions. And all without thehelpofaclinicalassistant! We all know the importance of plac- ing brackets correctly, but few of us can consistently and quickly place eachbracketpreciselywhereitneeds to be. With Insignia, you design the final occlusion and the customized appliances will be fabricated with custom torques, custom bases (in- out) and custom wires. You specify your bracket positioning preference (e.g., center of the tooth, more gingi- val or more incisal) so that the cus- tom appliances are designed to your specifications; thus, it is possible for your Insignia SL appliances to clini- cally match the placement of your direct-bondedappliances. To transfer the Approver-designed appliances to the mouth, Insignia provides customized placement gauges that place the brackets in the right spot without need for adjust- ment (Fig. 4). The precision built into the brackets is matched by the ac- curacy of the placement gauges that offerthebenefitofadirectviewwith the precision of planned indirect bonding. The major challenge in conducting this clinical evaluation was logistics. Managing treatment from so far away was a daunting experience at first;however,theprocessreinforced the importance of good clinical deci- sion making and its impact on clini- cal efficiency. Gone was the luxury of shortening patients’ appointment intervals to accommodate case management alternatives when we need to make clinical decisions based on how a patient responds. It wasthusincumbentuponmetocre- ate mechanical systems that would withstand the eight- to ten-week ap- pointment cycle of my West Coast trips. At six months, the first patient fin- ished treatment and by December 2009, after just 21 months, the 41st patient had his appliances removed. To determine the value of custom- ized Insignia SL for my own practice, Fig. 2. The Insignia Approver software gives clinicians unprecedented flexibility andcontrolindesigningcaseoutcomes. Fig.1a-b.T1andT2withbrackets Fig. 5. Breakdown of 41 Cases in Clinical Evaluation Class I – 19 Cases » 5 were Class I, div 2 Class II, div 1 – 11 Cases Class II, div 2 – 5 Cases Class III – 6 Cases » 3 were Class I with Class III tendency » 3 were full Class III Dental Tribune Middle East & Africa Edition | 1/2017 ORTHO TRIBUNE E2

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