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customized orthodontics 2

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ahmed zaky

on 11 December 2012

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Transcript of customized orthodontics 2

Customized Orthodontics When you see the title “Customized Orthodontics”, what comes to your mind? What we will discuss today: History Invisalign (Align Tech.) The habit of shopping and buying the same bracket prescription for every patient or the same arch form has to be rethought. Some forms of customized orthodontics we use in our everyday life are: Numerous variables influence treatment efficiency and outcome in orthodontics: Invisalign
Sure Smile
Insignia Dr H. D. Kesling, and the use of a flexible tooth positioning appliance. Invisalign takes the principles of Kesling, Nahoum, and Raintree Essix even further, Conveyor robot These models are then used to fabricate the aligners on a Biostar pressure molding machine (Great Lakes Orthodontic Products, Tonawanda, NY). The orthodontist’s prescription is followed in positioning the teeth and the bite to proper alignment. Invisalign virtual orthodontic technician (VOT) uses software to “cut” the virtual models and separate the teeth. Manufacturing:
The impressions are poured up in dental plaster and then placed in a tray and encased with epoxy and urethane. Stereolithography machines, stereolithography models, and aligners Automated aligner cutter Automated Aligner Former When the orthodontist has approved the treatment plan, the aligners will be manufactured. Significant overcorrection of rounded teeth might
be necessary, in addition to facial and labial attachments
or auxiliaries The VOT moves the teeth virtually to achieve the proper occlusion Cutters separate teeth, and placement of virtual gingiva. Clinical Procedures:
For each patient, the orthodontist submits a set of
polyvinyl siloxane impressions,
a centric occlusion bite registration,
a panoramic radiograph,
a lateral cephalometric radiograph,
and photographs to Align Technology. Stepwise procedure
mild to moderate crowding (1-6 mm), Indications A study in 2007 showed that Adults treated with Invisalign aligners experienced less pain and fewer negative impacts on their lives. Invisalign in literature Destructive scanner 3-D computer model Treatment-outcome assessment of Invisalign (Align Technology, Santa Clara, Calif) vs braces was analyzed in a study in 2005.
According to the OGS, Invisalign did not treat malocclusions as well as braces in this study. Every orthodontic patient deserves diagnosis, treatment plan and appliances specifically tailored for him/her. 6.not to mention misdiagnosis and malpractice. 5.ability to accurately monitor treatment 4.manufacturer tolerances, operator acuity and fatigue, 3.variations in adhesive thickness, 2.wire bending, wire selection, 1.errors in bracket placement, In simple words invisalign represents the sequential removable orthodontic appliances (aligners) to move teeth in a stepwise fashion. The Invisalign system is offered in more than 45 countries and has been used to treat more than 1.5 million patients. Foundation Raintree Essix (New Orleans, LA)uses clear aligners formed on plaster models of the teeth. Nahoum and others wrote about various types of overlay appliances such as invisible retainers. CAD-CAM technology combined with laboratory techniques fabricate a series of custom appliances that are esthetic and removable, and that can move teeth from beginning to end. The major steps involved in the fabrication of most modern customized appliances are: A computer linked with the scanner then assembles the scanned information to create a rendering of the models. The tray is placed into a destructive scanner. A virtual gingiva is placed along the gingival line of the clinical crown to serve as the margin for the manufacturing of the aligners . The number of stages necessary depends on the amount and complexity of the movement. Tooth movements are staged so that there are no occlusal and interproximal interferences,
and the velocity of the movements is within the criteria set by the company. The aligners are trimmed and laser-etched with the patient’s initials, case number, aligner number, and arch (upper or lower). However, movements are limited to 2 to 3 mm; beyond this range, another impression and a new appliance are needed. The computer images are converted to physical models by using a process called stereolithography. Suresmile Once the orthodontist selects a target treatment plan, the information is sent via the Internet to a server at OraMetrix, Inc. Once a goal or a treatment target is chosen, the operator can implement therapy by “virtual bracket placement” and select the archwire sequence and progression. SureSmile’s concept is focusing on the wire instead of the bracket to achieve ideal results SureSmile drastically changed the treatment process. Copper nickel titanium is the workhorse in the suresmile process.
It can be placed in fairly crowded dentitions, and it has all the 1st-, 2nd-, and 3rd-order bends to finish the case. The operator can run and modify various treatment scenarios and simulate treatment until the optimal treatment plan is found. The Windows-based software allows the operator to diagnose, plan treatment, and simulate the result. Image acquisition:
The SureSmile process begins with a direct 3-dimensional scan of the patient’s dentition using the OraScanner (OraMetrix).
The scanner is passed over the teeth to allow visualization of all tooth surfaces, including undercut areas.
The process takes approximately a minute and a half per arch. Virtual teeth “sliced” to show interferences.
A. Occlusal interference. B. Bracket interference. Sure Smile(OraMetrix, Dallas, Tex) Insignia (Ormco) Imagine a tooth severely rotated that we can’t get the bracket on the center line of the tooth.
Insignia CDTs will check everything once more. Centric Contacts:
By turning off the root forms, it is possible to examine the occlusion for occlusal contacts. In a second software suite, the occlusion is then constructed based on the skeletal information and dental landmarks on the tooth objects. Maintaining arch forms will ensure that treatment will progress quickly as teeth are maintained in trabecular bone as much as possible. Data capture:
Accurate PVS impression as well as radiographic and photographic information. Clinical
• Accuracy of result
• Inadequate utilization of auxiliaries
• Length of Tx due to round tripping
• Length of Tx due to prolonged finishing
• Upsetting of existing buccal occlusion If IPR is needed to accommodate a deeper bite, the Approver software provides a map revealing precisely how much is needed and where. Finally, all the interproximal spaces are filled with short root forms from a library. Landmarking: This is done automatically by software functions that can find and trace the gingival sulcus of the teeth. Brackets
• Innacurate positioning
• “Average” design brackets
• Poor fit of bracket base to tooth
• Need for repositioning brackets Causes of errors in treatment The photographs below are 90 days and 2 appointments apart. Copper Ni-Ti®, TMA® or stainless steel can be manufactured in virtually any cross-section. Thank You Special Thanks
Hesham and Mais Stepwise Procedure With sophisticated data registration and management techniques, the images are processed, and a computer model of the dentition is produced in real time. The operator assists in identifying the teeth.
Once this process is completed, the teeth can be moved like independent objects in 3 dimensions with the software controls. Invisalign (AlignTech.) There, indirect bonding trays and archwires are created and shipped to the orthodontist. The archwires are produced with a wire-bending robot in the sizes and shapes selected by the orthodontist. If the teeth are really out of alignment, the orthodontist can order a wire with the bends reduced by 50%, or by any percentage desired, for easier placement. Orthodontists were used to making treatment decisions on the fly at each patient visit. It is a precise, start-to-finish process that works with Damon, Inspire ICE, and conventional appliances. Insignia (Ormco, Orange, Calif) offers custom-designed orthodontic appliances via fully interactive software. Wires
• Lack of fit
• Inadequate arch coordination
• Inability to adjust nickel-titanium arch forms
• Need for wire bending Treatment Plan
• Inability to forecast result
• IPR prediction These impressions can then be digitized to get an extremely precise mathematical model of the patient’s anatomy. Stepwise Procedure Skeletal Mapping:
From these impressions information is first derived to describe the shape and size of the cortical limits of the mandibular bone. Segmentation: The next step is segmentation of the individual teeth from the whole arch model. The automatic function isn’t perfect so it’s sometimes followed by a manual touchup procedure. These landmarks are well known and consist of Crown-Long Axis (centroid of the crown), centric stops, occlusal tables on posterior teeth as well as some constructed landmarks. CAD/CAM programs work better with geometric objects than with flowing anatomical teeth. So, landmarks are applied to make the tooth objects computer friendly. Root Forms: This method gives the most accurate information regarding the need for interproximal reduction. This way the teeth are created as a solid object that can be assembled into an occlusion later by actually contacting themselves interproximally. Construction of the Occlusion: The software takes into account considerations like cuspid function and tooth size discrepancies.
The certified dental technicians (CDT) can make small changes to the occlusion at this point to provide as many contacts as possible. The appliances are not fabricated until the orthodontist has reviewed the virtual setup and approved the treatment plan. Appliances that are designed at this time are brackets, wire forms and precision placement devices. Appliance Design:
After the occlusion has been derived, the software proceeds to reverse engineer the appliances. 3D Interactive Approver™ Software:
Immediately after the case design is completed,the orthodontist will receive an e-mail containing a link signaling that his/her case is ready for evaluation. The Insignia Approver is completely real-time 3D interactive. This means that the orthodontist have control over virtually every aspect of the case. Not only that, but once the cases are downloaded, they have the freedom to review them anywhere. Changes are easy. The SmileArc™ feature allows to alter the overbite in smooth proportions by just grabbing a handle and moving the mouse. Insignia Appliances:
Insignia appliances consist of brackets and tubes, a series of archwires and precision bracket and tube locating devices. Insignia twin brackets, Inspire ICE™ aesthetic brackets or Damon™3 brackets. The greatest flexibility currently available is with the Insignia twin bracket. Wires are the engine that drives the system. To get a more clearer understanding of what insignia appliance does, This means that, although the bracket looks wrong, the slot is actually right where you want it. Normally, we would derotate the tooth . The biggest conceptual change is to understand that treatment is directed not so much by the wire, but the slot.(unlike suresmile) Positioning devices are manufactured from an engineering foam.These devices are color-coded and labeled for ease of identification. There are many forms of customized orthodontics in the market: and many others 3-Appliance fabrication (STL,CAD CAM,Robots) 2-Virtual treatment planning (software) 1-Data acquisiton (PVS impressions,CBCT,Specific scanners) Suresmile Incognito OrthoCad IQ Harmony Invisalign Insignia ITero and relapse after fixed appliance therapy. nonskeletal constricted arches, mild to moderate spacing (1-6 mm), The VOT can now send the data to the referring orthodontist so that he or she can check the proposed treatment on the Invisalign Web site.(Clincheck) Stereolithography (SLA; also known as optical fabrication, photo-solidification, solid free-form fabrication and solid imaging) is an additive manufacturing (or 3D printing) technology used for producing models, prototypes, patterns, and production parts. After that wire has been used, I can order and place a wire with 100% of the necessary corrective bends Almost always, in cases with worn or mutilated occlusions, compromises can be made that preserve aesthetics and provide increased function. Archwires are matched not only to the skeletal arch form of the mandible but also to the dentition of both arches. Insignia manufacturing techniques provide accurately formed archwires . Consequently, Insignia can encourage a final occlusion from the first day of treatment. With Insignia, the slot might actually be cut at an angle to accommodate the position of the bracket;
By Ahmed Zaky
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