Anchorage, alignment, and imagery

/Home/Dental Care and Treatment/Corrective Dentistry (Orthodontics)/Corrective Dentistry (Orthodontics) Articles

Anchorage, alignment, and imagery
2007
DPR World

DPR: What have been the hottest topics in orthodontics, specifically concerning implants, in the last year?

Dr. Mark Hochman: Implants and orthodontics is a very broad topic today, and you can look at how the use of combined therapy is evolving from several different viewpoints. Initially, the relationship between orthodontics and implant dentistry was one in which orthodontics provided some alternatives to implant dentistry by providing a regenerative procedure for supporting hard and soft tissues (bone and gingiva), to allow implants to be placed more effectively within a surgical site. Orthodontic therapy provided the ability to accomplish the esthetic reconstruction of those patients with greater predictability.

The ability to use conventional techniques such as forced eruption to improve both the bony and the soft-tissue architecture as an adjunctive procedure for implant dentistry now is fairly common when treating the complex esthetic-restorative implant patient. This interrelationship was the first phase of these combined techniques. Using conventional root-form implants as supporting anchorage units during orthodontics is another example of that first phase of combined ortho/implant techniques commonly used during the past two decades. Today, weÌre embarking upon a second phase of the integration. WeÌre now using specific implant systems to augment orthodontic treatment in a new way.

One should be aware, however, that even with the use of combined therapies, the basic biologic principles of these disciplines do not change. The basic principles of osseointegration do not magically change, either, because surgical techniques are now applied to a combined therapeutic approach. It should be understood that using implants doesnÌt necessarily allow you to move teeth faster through the supporting tissues; however, it does facilitate movement with less reliance on the necessary compliance of either the operator or the patient. Typically, adults donÌt tolerate certain types of auxiliary anchorage devices, such as an extraoral headgear appliance. Now, with the use of implants, or temporary anchorage devices (TADs), we no longer have to rely on that type of appliance to manage tooth movement. ItÌs more efficient because you donÌt have to rely on the patient or the operator to make the necessary adjustments to the mechanical system of tooth movement.

Important future developments will involve changes both in orthodontic biomechanical approaches to using these implants and in the surface design of the implants used specifically for orthodontic therapy. The biomechanical principles of orthodontics will have to evolve to optimize the easy use and efficiency of TADs. One of the requirements regarding their design is the ability to retrieve them at the completion of treatment. Therefore, surface design has to allow for removing them effectively, minimizing the difficulty of them becoming osseointegrated. Currently, smooth surface or polished titanium surface implants are used, but weÌre going to see refinement of these surfaces so they provide effective initial stabilization, ongoing support and anchorage, and then can be easily retrieved after use.

Dr. Brian Gray: To complete my Mastership in the Academy of General Dentistry, I took a number of hands-on orthodontic courses. Consequently, I dabbled with traditional orthodontics, but it never really fit into my practice. It wasnÌt until Invisalign (Align Technologies) came along that I was able to incorporate the type of orthodontics I wanted into my practice. I was actually one of the first GPs to use Invisalign and became certified with the first group six years ago.

ItÌs interesting that my referrals to orthodontists have not gone down; theyÌve gone up. IÌm now much more aware of adult orthodontics and am discussing it with patients. This system gives practitioners a chance to select the complexity of the cases they want to treat and to refer those beyond their comfort level to the specialist.

Something else thatÌs really hot is called Wilckodontics, named after two brothers (Dr. William Wilcko, an orthodontist, and Dr. Thomas Wilcko, a periodontist). The actual scientific term is Ïaccelerated osteogenic orthodonticsÓ (AOO) (Web: www.wilckodontics.com/dentists/

aboutheprocedure.html). They merge periodontics and orthodontics by flapping the tissue, cutting back the gum tissue, and placing dimples in the bone, usually with a slowspeed handpiece. That basically selectively decorticates or breaks down the bone. Next, you fill it with a demineralized freeze-dried bone (usually bovine xenograft) and put the flap back over it. Then, you move the teeth. What youÌve actually done is stimulated the bone to regenerate or remodel itself in between the teeth, allowing them to move fasterÛ weÌve seen cases documenting that theyÌre moving about three times as fast.

Cone-beam scanning also is huge right now. It provides more accurate detail of bone architecture, which enables you to evaluate tooth mass and eruption patterns. ItÌs excellent for implant placement. It can even give you a three-dimensional view of the pulp. Someday soon, weÌll be able to use a single cone-beam scan CT image to diagnose everything from tooth eruption to interproximal decay. People are wondering whether they should spend $40,000 to $50,000 for a digital panoramic, or three times that for 3-D imaging so they can place implants and look at tooth eruption, etc. In the next five years, itÌs really going to change the way we treat patients.



DPR: What time-honored protocols will always be regarded as best practices?

Dr. Hochman: We must understand and follow the basic biologic principles of surgical wound healing and osseointegration that have been proven to provide predictable outcomes to implant dentistry. Many of these principles were initially defined by Professor Per-Ingvar Br¬nemark and are still valuable tenets even as they relate to TADs used for orthodontics. These concepts are key to understanding how implants initially stabilize, then actually integrate, and how we eventually obtain absolute anchorage through osseointegration. Deviating too far from these time-tested principles will lead to a reduction in the success that weÌve come to expect in the last 30 to 40 years.

Dr. Gray: It really comes down to the six steps that we use everyday in practiceÛdiagnosis, records, treatment planning, initiating treatment, monitoring treatment, and completing treatment. That can apply to anything from a simple Class II composite to minor tooth movement. The key, obviously, is records. The better your records, the more confident youÌll be in your diagnosis, developing your treatment plan, and then initiating the treatment. In essence, the GP benefits from having the best records, being able to take the best records (such as cephalometric x-rays), and knowing how to use them once theyÌve taken them.