What Will Technology Bring Next? Dr. Ed Lin

Three-dimensional orthodontic treatment has become the standard of care in our orthodontic practice. In order for this transformation to have taken place in our practice over the years, there have been three major software applications that we have had to implement: i-CAT cone beam computed tomography (CBCT), Dolphin 3D and SureSmile. Prior to the implementation of these software applications, my experience with lingual treatment had been limited to two full orthodontic cases back in my residency days at Northwestern University, which had convinced me that I would never want to treat another full lingual case ever again. Isn’t that the beauty of technology? The development of a self-ligating lingual bracket, Innovation L (Dentsply GAC), and its ability to be utilized with SureSmile’s software applications, has created a costeffective and easy-to-use aesthetic treatment option that I can now offer my patients. In this article, I will discuss a patient who I treated with SureSmile (upper lingual and lower labial) in combination with i-CAT, Dolphin 3D and orthognathic surgery

Patient Information

This patient presented to me at his new patient examination in August of 2009 as an adult male age 27 and a half. He was healthy with one exception: He had been diagnosed with obstructive sleep apnea (OSA) approximately two years prior, which had been confirmed with a sleep study by his physician. For the past two years he had been treated with a dental sleep appliance made by a general dentist who specializes in sleep medicine. His chief complaint to me was that although he had good success in the beginning with the dental sleep appliance, over time, he had noticed a change with his bite and then he began to develop temporomandibular joint (TMJ) dysfunction issues with clicking and facial pain. As a result, he began to research other treatment options for OSA and came across orthodontics and orthognathic surgery as a viable option that could potentially cure his OSA.

Diagnosis and Etiology

Intra-oral examination revealed a Class III malocclusion. He had an overbite (OB) of zero percent and overjet (OJ) of -2mm. Minor lower incisal wear was present due to his OB/OJ relationship. Arch length deficiencies were present of 6mm in his maxillary arch and 4mm in his mandibular arch. Arch forms were asymmetric and tapered with bilateral posterior crossbite present. Periodontal evaluation revealed overall normal and healthy gingival tissue. However, there was some minor gingival recession present in his lower anterior dentition, which I believe was due to forces translated to his anterior dentition from the wear of his dental sleep appliance (Fig. 1).

Frontal facial evaluation revealed a balanced and symmetrical facial pattern. Profile facial evaluation revealed a straight profile with normal chin. His nasio-labial angle was obtuse at 130 degrees. Both upper and lower lips were competent at repose. However, his lower lip was slightly protrusive in comparison to the position of his upper lip. A frontal smile evaluation revealed acceptable upper and lower smile lines with buccal corridors present. There were no maxillary or mandibular cants present (Fig. 1). A single i-CAT CBCT scan was taken (13cm height at 0.4 voxels for 10 seconds). Using Dolphin 3D, cephalometric analysis revealed a Class III skeletal relationship with ANB=0 due to a mid-face deficiency with SNA=78 (Fig. 2).

A single i-CAT CBCT scan was taken (13cm height at 0.4 voxels for 10 seconds). Using Dolphin 3D, cephalometric analysis revealed a Class III skeletal relationship with ANB=0 due to a mid-face deficiency with SNA=78 (Fig. 2).

Panoramic evaluation from the CBCT scan revealed that all third molars had been extracted. Alveolar bone height in both maxillary and mandibular arches looked healthy and within normal limits. There were no other significant findings (Fig. 3). Tomogram analysis of his TMJs revealed normal and healthy looking mandibular condyles with no evidence of degenerative joint disease (Fig. 4).

An airway analysis utilizing Dolphin 3D from the CBCT scan revealed Airway Area=1068.0mm2 and Airway Volume= 25,361.8mm3 (Fig. 5).


Treatment Summary

This patient was referred to an oral surgeon, Dr. Vijay Parmar, for an orthognathic surgical consultation. The treatment plan recommended for the patient consisted of full fixed orthodontic treatment in combination with two-jaw orthognathic surgery for correction of his malocclusion and OSA. The patient was also interested in an aesthetic treatment option for his orthodontic treatment. As a result, the patient elected to pursue lingual treatment in his upper arch and labial treatment in his lower arch with SureSmile. From the start of his orthodontic treatment until his surgery, the patient utilized a continuous positive airway pressure machine (CPAP) for management of his OSA, although he did have some difficulty tolerating the CPAP machine.
In September of 2009, 0.018 In-Ovation L fixed lingual appliances were placed in his maxillary arch for U7-7 and In- Ovation C and R fixed labial appliances were placed in his mandibular arch (Dentsply GAC) for L7-7 using an indirect bonding technique. On this same day, the patient also began the SureSmile process, which is referred to as a “Fast Track” among SureSmile users (Fig. 6). After the brackets were placed, all bracket doors were closed in preparation for the i-CAT/SureSmile CBCT scan. A wax bite was taken with condyles seated in the glenoid fossa and ~3mm of separation between maxillary and mandibular dentition. Without archwires and with the wax bite present, the i-CAT/SureSmile CBCT scan was then taken with an i-CAT Classic machine (8cm height at 0.4 voxels for 10 seconds). It is necessary to have separation between the maxillary and mandibular dentition with the wax bite to enable SureSmile’s digital lab technicians to create the clinical crown anatomy in its SureSmile CAD/CAM software application. An initial G&H round 0.016 CuNiTi mushroom-shaped, lingual archwire was placed in his maxillary arch and an initial Bioforce Sentalloy rectangular 0.018 x 0.018 straight archwire was placed in his mandibular arch. Open coil springs were also placed distal to his UR2, UL2 to create spaces in preparation for his orthognathic surgical procedures.


A SureSmile pre-surgical plan was created treating the maxillary and mandibular arches independently for ideal leveling and aligning of all rotations, parallelism of all crowns and roots, and of the marginal ridges (Fig. 7). In November of 2009, six weeks after beginning his orthodontic treatment, the patient returned for placement of his robotically bent initial SureSmile archwires (maxillary - 0.016 x 0.022 lingual CuNiTi and mandibular – 0.017 x 0.025 labial CuNiTi) (Figs. 8 and 9). In January of 2010, the patient returned for placement of his second maxillary SureSmile archwire (0.017 x 0.025 lingual CuNiTi). In March of 2010, the patient returned and using SureSmile’s software applications at the clinical chair, minor virtual wire modifications were made to level some posterior marginal ridges and for torque correction of his UL7 to ideal. These SureSmile wires (maxillary – 0.017 x 0.025 lingual CuNiTi and mandibular – 0.017 x 0.025 labial CuNiTi) (Figs. 10 and 11) were then inserted three weeks later.

In May of 2010, pre-surgical records were obtained for the patient and plastic labial buttons were placed on the maxillary dentition for vertical elastics to be worn after his surgery, since this patient was being treated with lingual fixed appliances (Fig. 12). The appropriate virtual treatment outcome for his orthognathic surgical procedures was then determined between the oral surgeon, Dr. Parmar, and myself utilizing Bill Arnett’s Surgical Module in Dolphin Imaging (Fig. 13). These measurements were then transferred over for model block surgery to create an intermediate surgical guide to be utilized during the surgery for repositioning of his mandible and maxilla. In July of 2010, the patient underwent two-jaw orthognathic surgery. The orthognathic surgical procedures consisted of surgery first in the mandible with mandibular advancement and counter-clockwise rotation of the mandible, in combination with a maxillary threepiece osteotomy with expansion and maxillary advancement. Rigid fixation was utilized in combination with vertical traction elastics to stabilize the osteotomies. There was no final splint utilized post-surgery. The patient returned for a post-surgical evaluation two weeks after his surgery (Fig. 14). The patient stated that there was little postoperative pain and there was only slight numbness in the maxillary anterior tissue. A second post-surgical evaluation was done two weeks later in August of 2010. The patient stated that he was eating very comfortably and that his breathing and sleeping had significantly improved.

In September of 2010, a second i-CAT/SureSmile CBCT scan (8cm height at 0.4 voxels for 10 seconds) was performed for the patient to capture the patient’s occlusion after orthognathic surgery. A post-surgical SureSmile plan was created for the patient (Fig. 15). The robotically bent SureSmile wires (maxillary – 0.017 x 0.025 lingual CuNiTi and mandibular – 0.017 x 0.025 labial CuNiTi) were then inserted in October of 2010. In January of 2011, the patient’s orthodontic treatment was completed with the removal of his fixed orthodontic appliances. He was then moved into retention with an Essix ACE retainer with full-time wear and an L3-3 fixed lingual retainer wire. Three months later, the patient returned for final records and the wear of his upper Essix ACE retainer was reduced to bedtime only (Fig. 16).

Summary and Conclusions

Total treatment time for the patient was 16 months and six days. Total number of appointments for his entire treatment was 18, including four emergency appointments to replace two brackets and two plastic buttons. The patient states that his OSA has been completely corrected and he sleeps very comfortably at night. He no longer needs a dental sleep appliance or CPAP machine. A videotaped personal testimonial was also taken describing his experiences during the course of treatment. A follow-up sleep study was performed by his physician to confirm correction of his OSA. A post-surgical airway analysis utilizing Dolphin 3D from the postsurgical i-CAT/SureSmile CBCT scan revealed increases in Airway Area=1219.7mm2 from 1068.0mm2 and Airway Volume= 28,936.9mm3 from 25,361.8mm3 (Fig. 17). As a result, his treatment has resulted in an increased Airway Area and Airway Volume of 14 percent. A final cephalometric analysis revealed that ANB=2 and had been corrected to a Class I skeletal relationship. Final SNA=82 and his orthognathic surgery had corrected his mid-face deficiency to within normal limits (Fig. 18).

By combining different state-of-the-art 3D software applications that are available to our orthodontic profession today (i-CAT, Dolphin 3D and SureSmile), this patient’s treatment was completed entirely with 3D orthodontics. Utilizing self-ligating lingual brackets in his maxillary arch in combination with SureSmile CuNiTi wires provided the patient a cost-effective and easy-to-use aesthetic treatment option with complete control during treatment. SureSmile is currently the only lingual 3D software treatment application that gives the doctor and patient the option of treating only in one arch or both arches. Because we are utilizing CuNiTi wires with self-ligating lingual brackets throughout the course of his treatment, this makes treatment for the clinician much easier and more appealing as there are no wire bends that need to be made manually with pliers and engagement of lingual CuNiTi wires with lingual self-ligating brackets is not a difficult thing.

As I mentioned at the beginning of this article, I never thought I would be treating patients ever again with lingual appliances because of my experience with lingual during my orthodontic residency. However, technology has changed the way we all practice. Prior to SureSmile with lingual, I would have never thought it possible to be able to complete a full lingual case in only 16 months. But to do this in combination with two-jaw orthognathic surgery is truly amazing! Without a doubt, lingual treatment with SureSmile has been a big adjunct for me in my practice over the past two years. I would strongly encourage my colleagues to evaluate this as aesthetic treatment in strong demand with our patients. Who knows what technology will bring next!

Author's Bio

Internationally recognized speaker, Dr. Ed Lin, is a full-time practicing orthodontist and partner at both Orthodontic Specialists of Green Bay (OSGB), in Green Bay, Wisconsin, and Apple Creek Orthodontics (ACO) in Appleton, Wisconsin. Dr Lin received both his dental and orthodontic degrees from Northwestern University Dental School (‘95 - DDS and ‘99 - MS).