PUBLISHED IN DUBAI www.dental-tribune.me January-February | No. 1, Vol. 9 Interview: “It is not magic—it is not going to make the diagnosis for you...” SUBSCRIBE NOW https://me.dental-tribune.com/e-paper issn 1868-3207 • Vol. 3 • Issue 1/2018 ortho international magazine of orthodontics 1/18 By Dental Tribune MEA The Ormco Forum Dubai 2018 took place from 06 to 08 December 2018 at Palazzo Versace, Dubai, UAE Dental Tribune had a pleasure to ask the key speakers of the Ormco Fo- rum Dubai 2018 about the Damon System. Could you please share more about yourself? Dr Firas Hamzeh: I am simply an or- thodontist, working in a private prac- tice in Dubai, who has a special inter- est in digital orthodontics and all the new concepts in orthodontics. I am always willing to give the best treat- ment options to my patients. Over the past few years, I have become an educator for Damon System and Insignia and I started spending more time educating other doctors and sharing my clinical experience with them. Dr Bill Dischinger: I am a licensed orthodontist in the United States of America and I received my certi- ﬁcation in 1999. I have two private orthodontics practices in the north- west area of America. I also teach at the University of the Paciﬁc’s Or- thodontics Department in San Fran- cisco. Dr Matias Anghileri: I am from Bue- nos Aires, Argentina. I am married to a dentist and we have been together since our ﬁrst year at university. We have two kids, aged 6 and 8. I have been a full practice orthodontist for the past 16 years. I am the third gen- eration of dentists in my family and I enjoy my work every day in my of- ﬁce, as well as my work as an educa- tor. When did you ﬁrst hear about the Damon System? Hamzeh: It was in 2003, and I started using the Damon System in 2004. A few years later I became an exclusive Damon user. Dischinger: I ﬁrst heard about the Damon System—as presented by Dr Damon himself—during my residency in 1998. It was an amazing paradigm shift with regards to my way of thinking about orthodontics. Anghileri: It was 15 years ago at a con- ference. I was completely amazed by the system and its results. What prompted you to provide it as a solution in your practice? Hamzeh: It is the quality of treat- ment that we got at the end and the entire Damon System philosophy that made me change my mindset of how I was treating my patient. I especially like the concept of using light forces, reducing the number of extractions in my practice and the quality of the ﬁnishings. Dischinger: Immediately after hear- ing Dr Damon teaches about his sys- tem, I decided that it was how I was going to treat my patients. From the viewpoint of pure biology—of how to move teeth in a healthy, non-inva- sive manner—the system just made sense to me and I wanted to use that effectively in my practice. Anghileri: I felt that by using the Damon System I was going to pro- vide better results to my patients in a shorter time. Could you explain what Damon braces are? Hamzeh: I do not call them Damon braces, in fact, I call it the Damon System. I do not deal with the braces as a new product or as a new bracket with special features—it is a philoso- phy and a new treatment concept. If we use the Damon braces, we should use the Damon protocol and the Da- mon mechanics, because if we use the Damon braces with traditional or conventional mechanics, we will not obtain the results we are aiming for. With the Damon System, we apply very light forces to the teeth that are very close to the physiologic forces. Considering both aesthetics and functionality at the same time, we reduce the treatment time with less sessions and more clinical efﬁciency. One more point worth mentioning, is that we do not only treat teeth and jaws, we treat faces, which is why we call it “face-driven orthodontics”. Dischinger: Damon braces are a type of brace that holds the wire in place using a gate or a door system rather than the wire having to be “tied into” the brace. By doing this, the amount of friction that the brac- es and the wires have within their system is reduced. If the system has less friction within it, then the wires do not have to be so strong or have to apply as much force to move the teeth, since they do not have to overcome all that friction. It is kind of like moving furniture on a car- pet; compared to moving furniture over hardwood or tile ﬂooring. Think about the force you would need to push the furniture across in each of those instances. Anghileri: Damon braces are, from my point of view, a turning point in modern orthodontics. Undoubtedly, self-ligating brackets are the present and future of our specialty. Since the launch of the ﬁrst version in 1996, we have seen that every company has developed this type of bracket. What are the main advan- tages of the system? Hamzeh: The main advantages of the Damon System are a reduction in treatment time with less sessions and a reduction in the number of extractions. No headgear or expand- ers are required (as with traditional braces) and the improved aesthetics and functional results of the system. Dischinger: As mentioned above, the force required to move the teeth with the Damon System is much lower than with traditional braces. This leads to less inﬂammation with- in the teeth, bone and gums, which allows the teeth to move more ef- ﬁciently, with little or no damage done to the body during the process. Dr Firas Hamzeh Dr Bill Dischinger Dr Matias Anghileri The teeth hurt less with this process (I know as I have had both types of braces in my mouth). This leads to a healthier, more biologically sound way of moving the teeth, in my opin- ion. Anghileri: Well, I think in your question is the answer. It is not just a bracket with a door. It is a system with three pillars—the three main concepts of the Damon philoso- phy—using low forces and prioritis- ing facial features, using high-tech- nology Copper NiTi archwires and ﬁnally, the solid bracket with more than 20 years of evolution behind it. What is the main differ- ence between the Damon System and other tradi- tional braces? Hamzeh: A lot of the mechanics are different from traditional braces, but the main difference lies with the philosophy of the Damon System. For example, with Damon System braces we use very light elastics on light wires from the very beginning, which we cannot do with traditional braces. We also use variable torque for the front teeth—based on each individual’s case—which we cannot do with traditional braces. Anghileri: We have to understand that the biology is always the same. A bracket or a system will not change that. However, I see the same posi- tive results every day in each and every one of my patients: teeth move faster and healthier, because of the low forces acting on them. The treatments turn out to be simpler and more comfortable for the pa- tient—with reduced treatment time. What are the overall re- sults of using the Damon System in a practice, not just clinically, but also in terms of patient loyalty? Hamzeh: Using the Damon System improves the entire patient journey during their orthodontic treatment. You will also end up treating more patients, because you spend less time and less sessions on the treat- ment, which affects the practice’s productivity, allowing the orthodon- tist to treat more and more new pa- tients, which would result in a better reputation. Dischinger: When we explain the Damon System process to patients, it just makes sense to them. They often ask us why is it that every- one does not use this system. Our answer is that it is more expensive than traditional braces and there is a learning curve required to get com- fortable and knowledgeable in using the system, because of these reasons, technique Accelerated treatment modalities in clear aligner treatment industry report Indirect bonding: Digital technique vs conventional method industry report Hybrid Aligner Therapy some doctors are hesitant to change. We have many patients come to our ofﬁce, because they are searching for a more natural way—a healthier way—of moving teeth or they have heard of the Damon System or have done research on it online. It has helped our practice to be known as one of the foremost Damon System practices in the world. Anghileri: Many patients come to my clinic asking for the Damon Sys- tem, because they have seen the re- sults on other former patients. When they start a Damon treatment with me, they know there is a guarantee of success. What would you say to your colleagues who are hesitant about using the system? Hamzeh: I would encourage every orthodontist to use the Damon System, but not with the same con- ventional mechanics that were used before. Follow the Damon System’s treatment protocol and use its me- chanics and compare the results and treatment time with previous results. Of course you cannot apply it only to a few cases, you need to treat more and more Damon cases. We keep learning from our mistakes and the mistakes of the others, which is also why we attend the Damon courses. Dischinger: Look at the biology of moving teeth. We are in the health care world and we need to do eve- rything we can to move teeth in the most efﬁcient, healthiest way we can. Take courses that teach you how to use the system and try some cases with it. You will immediately see the difference in how the teeth move, in the comfort to the patient and the overall efﬁciency of the cases being treated. Do not be afraid to make a change. Anghileri: It is not magic—it is not going to make the diagnosis for you—but I can assure you that if you are a good orthodontist, with the Da- mon System in your hands, you are going to achieve wonders in your patients.
E2 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 1/2019 Six keys to effectively using alveolar corticotomy A different perspective on surgically assisted tooth movement By Dr Raffaele Spena, Italy Introduction Alveolar decortication (corticotomy) has long been used with orthodontic treatment in order to accelerate or- thodontic tooth movement (OTM) while reducing the undesired effects of root resorption, loss of vitality, periodontal problems and relapse of the corrections. The acceleration of tooth movement should shorten the therapy. However, the scientiﬁc and clinical assumptions of the early days were totally different from the more recent ones: we moved from a pure mechanical approach to a bio- logical and physiological one. In 1983, Suya1 proposed a great im- provement of the surgical approach described in 1959 by Kole2 modify- ing the horizontal osteotomy in a corticotomy, avoiding the alveolar crest in the vertical cuts and elimi- nating the luxation of the blocks. He proposed this “corticotomyfacili- tated orthodontics” to treat adult pa- tients, ankylosed teeth and crowded malocclusions to avoid premolar extractions. Like Kole, Suya believed he was creating bony blocks and suggested accomplishing most of the movements in the ﬁrst three to four months of treatment before the fusion of the blocks (healing of the bone). The concept of corticotomy-assisted OTM drastically changed in 2001 after the publication of Wilcko et al.3 In this key case report, two adult patients received a selective cortico- tomy, along with alloplastic resorb- able grafts, to increase the bone level and avoid the risk of recessions. An accurate evaluation with CT scans before and after treatment, and histological sections in one case, al- lowed the authors to formulate a new hypothesis about what really happens at the bone level after cor- ticotomy. No movement of tooth– bone blocks, but a transient reduc- tion of mineralisation of the alveolar bone and modiﬁcations similar to those described by Frost4–7 during the healing of fractured bones and named “regional acceleratory phe- nomenon” (RAP) most likely occur. The surgery -orthodontic protocol proposed by Wilcko et al.3 has been subsequently patented as Periodon- tally Accelerated Osteogenic Ortho- dontics (PAOO). The claims of PAOO are (a) accelerated tooth movement with reduction of the total treatment time; (b) osteogenic modiﬁcations with transportation of the bony ma- trix, and ﬁnal improvement of hard- and soft-tissue support of the teeth treated orthodontically; (c) increase of the short- and long-term stability of the orthodontic treatment. So far, scientiﬁc evidence has been given only on the acceleration of tooth movement that is transient, and lasts as long as there is a RAP modiﬁcation in the alveolar bone surrounding the teeth. After more than one and a half dec- ades of clinical experience with al- veolar corticotomy, in light of the current literature published on this topic, six rules have been established that should be taken into account when considering using alveolar cor- ticotomy in a complex orthodontic case. These keys are the best way to ensure effectiveness and reduce the risk of producing no positive effect or, worse, causing damage. The six keys are as follows: 1. Alveolar corticotomy is to facilitate OTM. 2. Alveolar corticotomy has limited effect in time. 3. Alveolar corticotomy has limited effect in space. 4. A proper surgical procedure must be followed. 5. Proper orthodontic management after corticotomy must be per- formed. 6. Proper patient selection for corti- cotomy is essential. A detailed description of each rule follows. 1. Alveolar corticotomy is to facili- tate orthodontic tooth movement (Periodontally Facilitated Ortho- dontics) Speed is a fascinating issue in life. We like to go fast in cars, motorbikes, boats, airplanes and so forth. Speed in orthodontics is a different mat- ter. It is one of the main objectives of modern orthodontics to reduce treatment time, but we must recog- nise that a great number of variables may affect it.8–11 The initial difﬁculty of the maloc- clusion and tooth malposition, the age of the patient, the variability of the individual response to the treat- ment, the quality of the end result, and the patient’s compliance are just a few of the variables that should be considered. Numerous case re- ports have been published showing how treatment time can be reduced when patients are treated with corti- cotomy. Case reports, however, have limited scientiﬁc validity. Open-ﬂap corticotomies Flapless corticotomies · Periodontally Accelerated Osteogenic Orthodontics · Fiberotomy · Segmental corticotomy · Corticision · Any corticotomy performed during an open-ﬂap surgery · Piezocision Tab. 1: Surgical protocols for performing alveolar corticotomy. · Micro-osteoperforations The predictability and quantiﬁca- tion of treatment time reduction are still not scientiﬁcally possible. The additional expenses and mor- bidity associated with the use of alveolar corticotomy should always be carefully evaluated to determine whether they are worth the saving of few months. A shorter orthodontic treatment is desirable, but certainly not at the expense of a high- quality end result. Regarding OTM, numerous studies have shown that its speed is inﬂu- enced by bone turnover and the indi- vidual response to mechanical forces and it is not related to the level of the forces.12–15 Clinical experience con- ﬁrms this: there are slow movers and fast movers, but we are still far from recognising them. In addition to this variability, there is the temporary ef- fect of alveolar corticotomy, which we will discuss under the third key. A faster treatment may be a secondary advantage and may be obtained in a substantial way only in those “sim- ple” orthodontic cases that require a naturally short treatment. In conclusion, alveolar decortica- tion should not be combined with orthodontic treatment with the only objective of accelerating OTM and reducing treatment time: the risk of not obtaining either as desired may be high. Despite this scientiﬁc evidence against its major claims, alveolar cor- ticotomy has its place in orthodontic therapy. Let us consider the surgical insult and the associated RAP reac- tion produced at a biomechanical level: the increased metabolism, the transient reduced regional density (osteopenia) created by the increased osteoclastic activity, the reduced un- dermining resorption and hyalini- sation (we still do not know exactly what happens in humans) facilitate OTM. The decorticated tooth is less resistant to orthodontic forces and will be easier to move and will re- quire less anchorage. Spena et al. in two studies conducted on a total of 12 adult patients with Class II malocclu- sions treated with distalisation of the maxillary molars showed how max- illary molars could be bodily distal- ised with simple buccal mechanics and no anterior anchorage.16, 17 Cor- ticotomy was performed only on the teeth to be moved, thus reducing the anchorage needs and their resistance to distal forces. The term “Periodontally Facilitated Orthodontics”, instead of “Periodon- Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 9 tally Accelerated Osteogenic Ortho- dontics”, is used to describe a pro- cedure that has the primary goal of simplifying, enhancing and improv- ing OTMs that are difﬁcult or risky, from a biomechanical and biological point of view. The surgical procedure and the associated orthodontic treat- ment and biomechanics depend on the initial problems and the goals of every single speciﬁc treatment. This is in agreement with Oliveira et al.: corticotomies should be used to “… facilitate the implementation of me- chanically challenging orthodontic movements and enhance the correc- tion of moderate to severe skeletal malocclusions”.18 2. Alveolar corticotomy has limited effect in time Since the early studies of Frost on the biology of fracture healing, it is ÿPage E3
Dental Tribune Middle East & Africa Edition | 1/2019 ◊Page E2 ORTHO TRIBUNE E3 known that the altered metabolism of bone after a traumatic (or surgi- cal) event has limited duration: it is the natural search for equilibrium or homeostasis. The burst of hard- and soft-tissue remodelling starts a few days after the insult, peaks at the ﬁrst or sec- ond month, and returns to a normal pace after a maximum of four to six months. This RAP reaction, when ap- plied to the alveolar bone, causes an accelerated/facilitated movement of the teeth subjected to applied or- thodontic forces. The effect lasts for as long as there is this reaction, so for a limited part of an orthodontic therapy. This has been conﬁrmed by experimental studies on animals and by clinical studies on patients.19 Clinically, this temporary phenome- non leads to the need to perform the alveolar corticotomy when the RAP is necessary. Timing is fundamental. Alveolar corticotomy may be repeat- ed during the treatment with the objective of prolonging the effect.20 The effective beneﬁt, cost and risks must be taken into account. Sanji- deh et al. in a split-mouth study on foxhounds found that a second cor- ticotomy performed after 28 days in the mandible produced a higher rate of tooth movement and a greater total tooth movement.21 However, they concluded that proper timing for a second corticotomy needed to be better determined. Wilcko,22–24 Dibart25 and Mur- phy26, 27 claimed that continuously activated orthodontic forces applied after decortication may maintain a constant mechanical stimulation, and allow a prolonged osteopenic state during which teeth can be moved rapidly. In order to achieve this effect, they recommended seeing patients fre- quently (every two weeks) and con- tinuing the activation of the applied orthodontic forces. If not, reminer- alisation would complete the heal- ing process and bring the bone me- tabolism to a normal level. It must be said that these claims have never been demonstrated either clinically or histologically. 3. Alveolar corticotomy has limited effect in space The effects of alveolar corticotomy are localised to the area immediately adjacent to the site of injury.28 This ﬁnding is of outmost importance. Different surgeries may affect dif- ferently the resulting OTM. Glenn et al.29 and Tuncay and Killiany,30 in two experimental studies on animals published before the new trend on corticotomy, found that ﬁberotomy (a corticotomy limited to the crestal side of the alveolar bone) affected the rate of OTM and shifted the centre of rotation toward the apex of the roots, thus modify- ing the biomechanical behaviour of the teeth under the orthodontic forces. If the surgical insult is applied to a limited area of the alveolar bone (i.e. middle third and only buccal sur- face; Fig. 1), the RAP reaction will not be extended to the entire root area. The modiﬁcations at the bone level will be limited at the area of the de- cortication, and control of the apical and lingual sides will not be inﬂu- enced as desired. ÿPage E4 Fig. 10 Fig. 11 Fig. 12 Fig. 13 Fig. 14a Fig. 14b Fig. 13 Fig. 14a Fig. 14b Fig. 17 Fig. 18a Fig. 18b Fig. 18c Fig. 19a Fig. 19b Fig. 19c Fig. 19d Fig. 20 Fig. 21a Fig. 21b Fig. 22c
E4 ◊Page E3 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 1/2019 Fig. 22a Fig. 22b Fig. 22c Fig. 22d As a general rule, if a mesiodistal bodily movement or better control of the apical area are the biomechan- ical needs of the OTM to be achieved and enhanced (i.e. intrusion/extru- sion), the decortication needs to be extended to the entire alveolar bone surrounding the roots of the teeth, buccally and lingually (Fig. 2); if the movement is less complex or ana- tomical limitations of the surgical site impede an extended decortica- tion, the cuts may be limited in the direction of the OTM. These biome- chanical needs determine the type of procedure in both the openﬂap and the ﬂapless surgeries. been proposed. Most of them have been tried in the last 15 years on sev- eral patients. These surgeries may be divided into two groups: the open- ﬂap and the ﬂapless corticotomies (Tab. 1). 4. A proper surgical procedure must be followed Several surgical protocols for per- forming alveolar corticotomy have The original corticotomies were per- formed after raising a ﬂap. This type of surgery is still preferred when an extended or critical area of decortica- AD What is the ClearSmile Aligner? ClearSmile Aligner employs a series of plastic appliances, called aligners, to gently reposition and align the teeth creating a beautiful new smile. A L I G N E R Made in Dubai supervised by orthodontists in UK www.clearsmilealigner.com www.iasortho.com www.mdentlab.com Tel : 04-332901 Whatsapp +971 557590217 email@example.com tion has to be managed and when an extended grafting is planned. The ﬂap can be designed according to the periodontal characteristics of the site and has to be full thickness in the area of decortication and split thickness below this area to ensure a good blood supply. Interproximal and subapical cuts of 1–2 mm in the cortical bone (Figs. 3 & 4) are per- formed together with a light scrap- ing of the external cortex in between the cuts. This extended surgical in- sult will produce a wide RAP reaction and prepare a bleeding bed for any grafting material eventually placed in association with the decortication. Piezo- surgical calibrated micro-saws are preferred to rotating surgical burs because of their selective, safer, micrometric and more precise cuts; better irrigation/cooling effect from cavitation; better comfort for the surgeon; and better healing for the patient. The open-ﬂap corticotomy procedure is routinely used during orthognathic surgery, when expos- ing impacted teeth, to treat trans- verse maxillary deﬁciencies and periodontally involved cases. Flapless surgery has been proposed as an alternative way of performing a corticotomy. Corticision31 and Pi- ezocision32 have been an attempt to reduce the invasiveness of the decor- tication and the possible periodontal damage and postoperative discom- fort with raising a ﬂap. Even if attrac- tive, they seem to have surgical and biomechanical limitations. The surgical limitations include risks when performed in crowded arches, limited visibility when producing the cuts, limitation of the cuts to the interproximal areas and to the mid- dle third of the roots, difﬁcult control of the grafting in the apico-coronal direction and need for optimal ex- tension of the attached gingiva in the area of decortication. The bio- mechanical limitations are strictly related to the fact that corticotomy is performed only on the buccal side and middle third of the roots. They are deﬁnitely not minimally invasive surgeries as claimed and are quite expensive for the patient, since only a well-trained periodontist/oral surgeon can perform them and they often require complex planning with digitally designed 3-D surgical guides.33 The Micro–Osteo–Perforations (MOPs) described by Alikhani et al.34 and Teixeira et al.35 are an effective and minimally invasive way of pro- ducing insult to the cortical alveolar bone. These MOPs may be created with manual instruments (Excel- lerator, Propel Orthodontics) or with dedicated burs on a reduced-speed electric handpiece (Fig. 5). MOPs are produced with a penetra- tion in the cortex of a maximum of 1–2 mm. Instead of conventional lo- cal anaesthesia, a strong anaesthetic gel placed on the mucosa for three minutes is sufﬁcient to control the patient’s pain and discomfort. It is advisable to produce two to three MOPs in each interproximal area of the teeth and both buccally and lingually (Fig. 6), to ensure that the metabolic changes are extended around the entire radicular alveolar bone. Manual MOP is usually cre- ated in the frontal areas, whereas drilled MOP is usually performed in the posterior and lingual areas (Figs. 7–9). The procedure and the precau- tions are similar to the insertion of mini-screws. Orthodontists can eas- ily create MOPs at the chairside, and the cost is a great deal more afford- able for the patient. Finally, they can easily be repeated during treatment if additional bone stimulation is needed. No packing and no sutures are necessary after MOP. The limit is that no grafting can accompany MOP. Whenever possible and desirable, grafting may accompany alveolar corticotomy. The grafting is usually planned before surgery, based upon initial clinical and radiographic evaluation, the desired OTM, and the short- and long-term periodontal considerations. In situations of thin bone and a thin gingival biotype, with risky movements like expan- sion, labial proclination or antero -posterior movements in reduced bone volumes, grafting may be in- dicated to reduce/eliminate fenes- trations and dehiscences, produce additional support for the roots, and improve ﬁnal aesthetics and stabil- ity. Grafting may include hard-tissue, soft-tissue and autologous growth factors. Quality and quantity may be modulated at the surgery depend- ing on the clinical conditions of the surgical site. As a general rule, com- posite bone grafts where allogeneic bone (bone from human cadavers that is freeze-dried to reduce anti- genicity and demineralised to ex- pose the underlying collagen and its growth factors, like bone morphoge- netic protein) with osteoinductive properties, is mixed with xenogenic bone (bone usually from bovine ani- mals that provides a physical matrix or scaffold suitable for deposition of new bone and that prevents its rapid resorption) with osteoconductive properties are preferred (Fig. 10). Soft-tissue grafts are added to bone graft when a thin biotype or gingival recession is present. If the area to be regenerated is small, an autologous connective tissue graft is the gold standard procedure. Large areas may be managed with allogenic human acellular dermal matrices, that are available in different sizes and thick- nesses (Fig. 11). Soft-tissue grafts are sutured with resorbable sutures. Both bone and soft-tissue grafts are coupled with autologous growth factors. With age- ing, the number of stem cells rapidly decreases. These cells are important in case of injury and healing process- es. Studies have shown that growth factors from platelet- concentrated plasma (platelet- derived growth factor, vascular endothelial growth factor, transforming growth factor beta 1 and 2) may rapidly increase the number of the available stem cells, stimulate their activity, as well as reduce inﬂammation and pain dur- ing the healing processes.36 Platelet- rich ﬁbrin (PRF)37, 38 and the platelet rich in growth factors (PRGF)39, 40 are prepared via two different proto- cols in which blood centrifugations allow separation of the plasma plate- lets from the white and red cells. PRF contains leucocytes and the process for its preparation produces mem- branes with a light compression of the centrifuged fraction. The process for preparing PRGF al- lows the separation of three frac- tions with different concentrations of platelets. They may be mixed with bone grafts (increasing the graft’s vis- cosity and adherence to the surgical site, thus facilitating its application) and soft -tissue grafts. Activating and ÿPage E5
Dental Tribune Middle East & Africa Edition | 1/2019 ◊Page E4 ORTHO TRIBUNE E5 Fig. 23a Fig. 23b Fig. 24a Fig. 24b Fig. 25a Fig. 25b Fig. 26a Fig. 26b Fig. 27a Fig. 27b Fig. 28a Fig. 28b molar to molar and generous hard- and soft-tissue grafting (Figs. 24a & b). Treatment started a week after the surgery and continued with vis- its every two to three weeks. Once arch coordination had been slowly achieved with 0.019 × 0.025 in. stainless-steel archwires (Figs. 25a & b), followed by 0.021 × 0.025 in. stain- less-steel archwires (Figs. 26a & b and 27a & b), the anterior open bite spon- taneously closed (Figs. 28a & b). The CBCT images before and after treat- ment reveal the increased volume of the maxillary alveolar bone that allowed the successful expansion of the upper arch, despite the age of the patient and the initial periodontal problems (Figs. 29a & b). Conclusion Alveolar corticotomy (or periodon- tally facilitated orthodontics as we prefer) is an effective procedure in which alveolar decortication is asso- ciated with orthodontic treatment with the primary goal of enhancing OTM and reducing anchorage needs. By accelerating the rate of OTM and reducing the complexity of a clinical case, bone decortication may reduce treatment time. However, this effect is considered a side-effect and not the primary reason for using this periodontal surgery. According to the patient’s needs, it may be per- formed with an openﬂap or a ﬂapless procedure and may be associated with hard- and soft-tissue grafting. Further studies are still needed to evaluate indications, contra-indica- tions and risks. The procedures de- scribed here will certainly evolve and improve with the improvement of the materials, devices and appliances utilised. Editorial note: A list of references is available from the publisher. This article was originally published in ortho international magazine of orthodontics, Issue 1 2018. Dr Raffaele Spena Via dei Mille, 13 80121 Napoli, Italy firstname.lastname@example.org www.raffaelespenaortodonzia.it Fig. 29a Fig. 29b heating the PRGF fraction produces clots/membranes of ﬁbrin that are placed on the bone grafts, stabilising their position (Fig. 12). When using grafts along with alveo- lar corticotomy, a tension-free ﬂap closure must be achieved at the end of the surgery, to provide optimal coverage of the decorticated area and the grafted material, and to en- hance ﬁnal soft-tissue healing. Non- resorbable sutures are left for at least 14–21 days. 5. Proper orthodontic manage- ment after corticotomy must be performed Orthodontic treatment associated with periodontally facilitated ortho- dontics may be carried out with any ﬁxed or removable appliances. It is the clinician’s choice to combine periodontally facilitated orthodontic procedures with ﬁxed, active self- ligating appliances (In-Ovation) with the new prescription of the CCO Sys- tem (GAC-Dentsply Sirona; Fig. 13).41 The management and wire changes are similar to those of any ortho- dontic case. No initial heavy force is necessary. There is no rule regard- ing timing of the bond ing: in some cases, appliances are placed a week after the surgery, while in others (for example, when distalising maxillary molars or repositioning impacted teeth) several months before corti- cotomy. The enhanced tooth movement de- riving from the RAP reaction is ob- tained when needed. The major dif- ference is that, after the periodontal surgery and until tooth movement is clearly enhanced, the visits for wire activations or wire changes are every two weeks instead of the usual six to eight weeks. When corticotomy is performed along with aligner treatment, the fre- quency of appliance changes is every three to four days. Alveolar corticotomy may easily be associated with skeletal anchor- age devices. Temporary anchorage devices are used to increase anchor- age, while corticotomies are used to reduce anchorage. 6. Proper patient selection for corti- cotomy is essential Alveolar corticotomy is not for every patient, and it is not feasible to use it on a routine basis in clinical practice. The main indication is in clinical cases with complex OTMs. Open- ﬂap surgery is indicated in impact- ed teeth, surgery-ﬁrst procedures with orthognathic surgery with major postoperative extractions, OTMs, complex space closures with reduced supporting tissue, and maxillary expansion in periodon- tally compromised cases. MOP is in- dicated in treatments with aligners, complex OTMs without periodontal problems and patients with ﬁnancial limitations. One case treated with open-ﬂap cor- ticotomy and two cases treated with MOP will be shown to elucidate the concepts described in this article. Case 1 A 19-year-old male patient with a Class III dental malocclusion with an- terior midline discrepancy wanted to be treated only with aligners (Figs. 14a & b). Treatment was carried out with 71 aligners and two MOPs per- formed at the second month and at the ﬁfth month of treatment, only on the premolar and molar maxil- lary dentition (Fig. 15). Class III elas- tics were prescribed throughout the therapy. Treatment was completed in seven months with acceptable in- tercuspation in the buccal segments and correction of the midlines (Figs. 16a & b) and with good anchorage control in the lower arch (Fig. 17). Case 2 A 22-year-old female patient with a Class II, Division 1 dental maloc- clusion with a missing mandibular right ﬁrst molar and mandibular an- terior midline deviated toward the right presented for treatment (Figs. 18a–c). The treatment plan was to extract the maxillary ﬁrst premolars and close the mandibular right mo- lar space with minimum anchorage. MOPs were performed after inser- tion of the mandibular working wire (0.019 × 0.025 in., stainless steel; Figs. 19a–d). Nickel-titanium closed coil springs were applied right after the decortication (Fig. 20). Treatment was completed with good intercus- pation, coincident midlines and all spaces well closed (Figs. 21a–c). Fig- ures 22a to d show the dental pano- ramic tomograms and lateral cepha- lometric radiographs before and after treatment. Case 3 A 30-year-old male patient, after two unsuccessful previous orthodontic treatments, with a Class II maloc- clusion with an anterior open bite, a unilateral cross bite and generalised recession on the buccal aspects of maxillary teeth presented for treat- ment (Figs. 23a & b). The ideal treat- ment would have included surgi- cally assisted maxillary expansion, followed by combined orthodontic– orthognathic surgery. The patient refused this treatment, but accepted an alternative treatment with open- ﬂap corticotomy extended from
E6 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 1/2019 Align Technology reaches 6 millionth Invisalign patient milestone with tween patient from China By Align Technology Inc Align Technology, Inc. (NASDAQ: ALGN) today announced that over 6 million patients have begun treat- ment with Invisalign - the most ad- vanced clear aligner system in the world, including 1.4 million teenage patients*. This is a signiﬁcant mile- stone for the company and the over 150,000 Invisalign-trained doctors worldwide, reﬂecting accelerating adoption of Invisalign treatment by adults and teens alike. The 6 millionth Invisalign patient, Yuzhe, is a 12 year-old student of the International School of Beijing, who began treatment in October 2018 using Invisalign Comprehen- sive with Mandibular Advancement treatment with Dr. Jiawei Wo from Yuxueyuan Dental clinic. Dr Wo is a Gold Invisalign trained doctor based in Beijing, China who specializes in pediatric orthodontics. Dr. Wo prescribed Invisalign clear aligner therapy to his patient Yuzhe to address her class II type of teeth misalignment and because it ﬁt well into her busy, student lifestyle: “In- visalign treatment with Mandibular Advancement is great, because it moves the lower jaw forward, while simultaneously aligning the teeth. With the Invisalign system, my pa- tients need much fewer appoint- ments than with traditional ortho- align patient coming from China: “I was absolutely delighted and proud to hear that 6 millionth patient is from Asia Paciﬁc. China is our fast- est growing country market with approximately 70% annual growth rate**. I believe there is an enormous opportunity in the region for Invis- align providers to treat millions of young patients like Yuzhe. I would like to thank Dr Wo for his conﬁ- dence in treating Yuzhe with the In- visalign system, and Yuzhe’s parents for trusting that it is the best solution for their daughter.” In support of this major milestone for the company, Yuzhe will be fea- tured in an upcoming Invisalign global campaign, entitled “6 Million Invisalign Smiles” that will follow Yuzhe and her family through her Invisalign treatment journey. The campaign will highlight key reasons why she and her parents decided to choose Invisalign clear aligners to help her achieve a new, beautiful smile. Invisalign 6 millionth patient dontic appliances. This allows them to continue their studies and daily activities without interruption”. “We are delighted to be celebrat- ing another signiﬁcant milestone with Invisalign trained doctors and their patients. This achievement is a reﬂection of growing demand for Invisalign clear aligners from inter- national markets, especially China, which is our second largest coun- try market, nearly doubling each year since the Invisalign system was launched in China back in 2011. I would like to thank Dr. Jiawei Wo and all of the Invisalign trained doc- tors around the world for helping us make Invisalign treatment the clear aligner orthodontic method of choice among teens such as Yuzhe, as well as for giving our patients a chance to have beautiful, straight teeth and smile with conﬁdence” – said Joe Hogan, Align Technology president and CEO. Julie Tay, Align Technology senior vice president and managing di- rector, Asia Paciﬁc recognized the importance of the 6 millionth Invis- For additional information about the Invisalign system or to ﬁnd an Invis- align doctor in your area, please visit www.invisalign.com. For additional information about iTero digital scan- ning system, please visit www.itero. com. Interview: “We will continue to commit to our clients the best orthodontic customer service experience in the industry...” By Dental Tribune MEA Dental Tribune MEA had a pleasure to speak with Dr Ramy El Zoghby, Re- gional Saes Director – Dealers EMEA at Ormco. Dr. Ramy, congratulations on yet another successful year. The highlight of the year must have been the 3rd ORMCO Forum Dubai. How do you reﬂect on this unique event for the re- gions Orthodontists? I have to say that 2018 has been an exceptional year for Ormco in the region and the 3rd Ormco Forum in Dubai was the great highlight of this success through the whole EMEA re- gion. Another new and exceptional record of participation with more than 350 Orthodontists & 8 Interna- tional speakers coming from more than 15 countries all over the world, sharing their knowledge and clini- cal experiences using the most ad- vanced techniques in Orthodontics and deﬁnitely our unique products. How important is it for ORMCO to have such an- nual events and be close to your regional partners and clients? Ormco partners are a crucial part of our success in the region. We do our maximum efforts to ensure the best customer service experiences to all our clients especially in terms of con- tinuous products availability and on time delivery. Moreover, keeping our clients’ satis- faction at the highest level possible is one of our major goals within the whole Ormco organization. What was the base for the choice of your scientiﬁc speakers and content for the event? We tried to diversify the scientiﬁc content, and the speaker’s back- grounds taking the participants through an exciting journey during the three days. The delegates could discuss their concerns and ﬁnd out all the new updates in conven- tional esthetic systems, self-ligating techniques and digital orthodontic which is our future blighting trend in Ormco. The past year have been very dynamic, not only for ORMCO but also the den- tal industry. How do you manage to continue deliv- ering top quality products, services and education to your client base, distribu- tors and partners in the Middle East? I agree with you that 2018 was one of the most challenging and dy- namic years for the whole industry in the region, however, we success- fully completed the year smoothly by continuing to focus on the best products we sell in Ormco globally. In terms of education, more than 25 international scientiﬁc courses were conducted successfully, keep- ing our clients updated with the lat- est techniques and products. It also makes our partner’s job easier to deliver Ormco’ s message to the larg- est number of clients in the shortest possible timeline. In the year of IDS Cologne 2019, what can we expect from ORMCO and your Middle East partners? We will continue to commit to our clients the best orthodontic custom- er service experience in the industry whilst continuing to focus more and more on educating orthodontics. What are your plans for the region in the coming year? This year, we have an ambitious plan to increase our educational courses by more than 20% in comparison to last year, strongly participating in the big regional orthodontic confer- ences (i.e.: Saudi Orthodontic Soci- ety meeting – SOS in Jeddah/ KSA. Moreover, we will be having our 2nd Ormco Forum in Saudi Arabia in No- vember 2019 with more and more exciting speakers and topics. After the success of the 2nd MENA Symposium in 2015 Ormco has re- cently launched their 3rd edition of the Dubai Forum , that took place in Palazzo Versace Hotel between the 6th-8th of December 2018. Dr Ramy El Zoghby, Regional Saes Director – Dealers EMEA at Ormco. This is considered the biggest Ormco scientiﬁc event EMEA region with more than 300 participants and 8 international speakers from around the globe. Not only International speakers but also international del- egates from 15 different countries including Middle East, E, and East Europe, Russia and Africa all gath- ered to attend the big event as well as the launch of the 2 new products Damon Q2 and Symetri Clear and In- signia new technologies in the world of digital Orthodontics. Looking forward for more success in the next edition of the Ormco Forum
Dental Tribune Middle East & Africa Edition | 1/2019 ORTHO TRIBUNE E7 Ormco Forum Dubai 2018 Impressions 06-08 December 2018 | Palazzo Versace | Dubai | UAE After the success of the 2nd MENA Symposium in 2015 Ormco has re- cently launched their 3rd edition of the Dubai Forum, that took place in Palazzo Versace Hotel between the 6th-8th of December 2018. This is considered the biggest Ormco scientiﬁc event EMEA region with more than 300 participants and 8 international speakers from around the globe. Not only international speakers but also international del- egates from 15 different countries including Middle East, Europe, and East Europe, Russia and Africa all gathered to attend the big event as well as the launch of the 2 new prod- ucts Damon Q2 and Symetri Clear and Insignia new technologies in the world of digital orthodontics Looking forward for more success in the next edition of the Ormco Forum Participants Main Conference Dr Skander ELLOUZE, Mini Screw Lecture Main Conference Main Conference Damon Workshop with Dr Bill Dschinger TADs Workshop with Dr Skander ELLOUZE Damon Workshop with Dr Bill Dischinger Ormco team Ormco team with heads of Saudi Orthodontic Society New relaease of the MBT bracket Symetri Clear
E8 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 1/2019 3M Oral Care Ortho Programme Highlights Impressions from the 3M Oral Care Symposium orthodontic programme which took place in Abu Dhabi on 04-05 October 2018. Over 200 dentists and orthodontists attended. Dr Anoop Sondhi, USA presented two lectures as the keynote speaker on Contemporary Orthodontic Treatment with Self-Ligating Appliances as well as a full day seminar on TMD Dr Jose Chaques Asensi from Spain during his workshop on The Path to Excellence with Class II correctors. Dr Khaled Al Khayat, Kuwait presented The ABC’s of growing your Prac- tice Today. Over 40 delegates attended the TAD & Self Ligating workshop. Three parallel workshops took place on various hot topics Dr Abdelhakim El-Gheriani, UAE lecturing during the Ortho programme Prof Albert Waning from The Netherlands lectured on Prevention for Orthodontics, a new trend of clean, treat, protect and maintain the health of teeth. Seminar: Current Concepts in the Management of Temporomandibular Disorders by Dr. Anoop Sondhi, USA. The newly opened Grand Hyatt Hotel & Residences Emirates Pearl was the magestical venue of this unique symposium in Abu Dhabi, UAE. Dr Jose Chaques Asensi lecturing on How to Deﬁne Clinical Excellence Today.