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ePaper created 2018-03-13, 09:28:55 | version 1.38.0
| technique Accelerated treatment modalities in clear aligner treatment Dr Gary Brigham, US Adopting new technologies is critical to any orthodon- tic practice that aspires to expand and innovate in the twenty -first century. Responding to patients’ evolving needs is vital to establishing patient satisfaction with treat- ment and subsequent practice success. Accordingly, the capacity to offer patients unique treatment benefits that specifically address their principal concerns, is perhaps one of the most important driving forces to incorporat- ing acceleration technologies and adjunctive treatment modalities into practice. Significantly, when these tech- nologies are used in combination with other innovative treatments, such as clear aligner therapy, the resultant synergy can potentially result in markedly improved and timely treatment outcomes. Such is the case, I believe, with micro-osteoperforation (MOP) for acceleration of orthodontic treatment, and high-frequency vibration (HFV) for enhanced clear aligner seating and pain/dis- comfort reduction. I have found MOP to be clinically effective in acceler- ation of treatment and in enhancement of clinical results for a broad range of malocclusions, including crowding, space closure, molar uprighting, rotations, intrusions and extrusions.1–3 A research survey of adult patients has indi- cated that a majority were interested in any procedures that could effectively reduce their treatment time.4 My decision to implement MOP in my own treatment procedures arose from increasing requests from my patients to reach their orthodontic aesthetic and func- tional goals, within a time frame that aligned with their expectations as well as their own estimated capac- ity for compliance with treatment. Even with Invisalign’s current seven-day aligner exchange protocol, patients have expressed interest in further truncating their treat- ment time, without increasing the discomfort sometimes associated with tooth movement. MOP has proven to be instrumental in addressing these patient concerns in my practice. It can be performed chairside within several minutes using the Excellerator PT power driver with the disposable surgical grade Excellerator PT power tips. I find predictability and confidence in knowing this device is specifically designed and indicated for performing mul- tiple micro-osteoperforations in a single treatment. The procedure can be applied in both fixed and removable orthodontic appliance therapy, but is especially dramatic in its capacity to impact clear aligner treatment. The science underlying MOP is based in orthopaedics dating back over 100 years. In 1989, Harold Frost coined the term “Regional Acceleratory Phenomenon” (RAP) to describe this predictable remodelling response of bone to iatrogenic stimuli. Its premise suggests that disruption of the cell membranes of osteocytes, the most ubiquitous cell in bone, stimulates their secretion of a cascade of cytokines and chemokines that accelerate the physiolog- ical rate of bone remodelling.5–7 As research has demon- strated that the rate of tooth movement is dependent upon the rate of the physiologic process of bone remodelling, it is reasonable to surmise that an increase in the rate of bone remodelling should correlate with an increase in the rate at which clear aligners can be exchanged.3, 6–8 Use of the Excellerator PT device to create micro-osteoperfora- tions of the cortical plates of interseptal bone activates a chemically-based natural immune response, that accel- erates bone turnover and subsequent tooth movement when orthodontic forces are simultaneously applied.5, 6 The procedure conducted under topical, or local anaesthetic imparts minimal discomfort to the patient. To further mitigate any potential discomfort, the patient is instructed to take 1,000 mg of Tylenol one hour prior to the appointment. In preparation for conducting the MOP, a topical anaesthetic gel (12.5% lidocaine, 12.5% tetra- caine, 3.0% prilocaine and 3.0% phenylephrine) is spar- ingly applied and is supplemented with local infiltration anaesthesia using Septocaine (4.0% articaine HCL and epinephrine 1:100,000) in buccal and labial vestibule if needed. Following MOP, the patient is further directed to take 500 mg of Tylenol (acetaminophen) every six hours for the next 24 hours to alleviate any residual discomfort associated with the procedure. Significantly, a majority of patients have reported that they did not require the use of any post procedure analgesics. Case 1: MOP can especially be used effectively in conjunction with clear aligner therapy. For example, in Figures 1a and b, a 19-year-old female patient presented with a vertical Class II skeletal malocclusion four years post fixed appliance treatment. She demonstrated clini- cally a retrognathic chin point, an anterior open bite with inadequate incisal guidance, and dark buccal corridors. A treatment plan including adjunctive MOP therapy in conjunction with Invisalign Teen treatment was accepted by the patient, with the patient caveat that no elastics 30 ortho 1 2018