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A New Era in Digital Orthodontics by Jeffrey T. Kozlowski, DDS

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When speaking to fellow orthodontists, I'm frequently asked how I took the plunge to adopt 3D digital treatment techniques and I find many of my peers struggling with how to begin. My initial experience with customized Insignia SL began in 2007 when I conducted an extensive clinical evaluation by treating 41 patients to completion. While I wouldn't recommend selecting this many patients to begin treating with customized Insignia SL for the first time, I am convinced that the best way to learn Insignia is to submit cases regularly. Regular case submission allows the clinician to relate what is designed in the digital environment to the clinical experience and final results. This positive feedback loop of learning will help the clinician design each successive Insignia case with a higher level of understanding and accuracy and hence be more successful with its application. My experience has been that clinicians who regularly submit Insignia cases are more successful with it than those who start only a few cases and wait to see how they work out. My skills improved substantially through the first 10 to 20 cases, and like using any other new appliance, it takes a bit of time to learn the nuances. I also strongly recommend doctors initially select easier cases, and then add more challenging cases when they become familiar with the software and clinical protocols. This article highlights how Insignia works and demonstrates the practice, patient and treatment benefits.

Digital Orthodontics

A true straight-wire appliance would necessitate patient-specific appliances based on an individual’s anatomy. Now, with advances in computer software and digital scanning and fabrication, that idea is a reality and a practical consideration for your practice. Customized Insignia is the first true straight-wire appliance. It involves two components: customized appliances – brackets, wires and placement gauges – and 3D real-time virtual treatment planning software.

The 3D software enables clinicians to design the patient's final occlusion on screen before initiating treatment, then prescribes the fabrication of patient-specific appliances to achieve the planned result. This concept is quite different from how clinicians customarily practice orthodontics. Traditionally, we choose appliances with specific torque values to have certain effects, then react to those effects by repositioning brackets and making wire bends to guide the teeth into the desired positions. With Insignia, we begin with the end in sight and drive directly toward the desired end result.

After more than 20 years in development, customized Insignia appliances offer the only comprehensive patient-specific solution available. The treatment planning process begins with accurate PVS impressions. New clinical methods and materials make this procedure quick and easy. From the impressions, the pre-treatment malocclusion (T1) is digitized into a precise mathematical model of the patient's skeletal and dental anatomy and the proposed setup (T2) designed (Figs.1a-b). The setup is loaded to the Insignia web portal where, based on clinical experience, functional and aesthetic preferences and intimate knowledge of the patient's specific orthodontic needs, the clinician can easily customize it using the Insignia Approver software (Fig. 2). The included software offers clinicians control in determining accurate tooth position and in their ability to make changes directly to the 3D models without relying on an operator's interpretation of instructions.



As doctors modify the desired final outcome in the Approver software, they can view in "real time" how the changes affect the opposing occlusion. Once the clinician finalizes the ideal setup, the Insignia software engineers the customized brackets, wires and precision bonding placement gauges to the exact prescription required to deliver the designed end result accurately and efficiently.

My experience with Insignia is with both the customized passive self-ligating appliance (Insignia custom SL) and Insignia using stock Damon System appliances. The Insignia software can be used to fabricate patient-specific conventional twin brackets and aligners as well. You can also use Insignia software with stock appliances (Orthos, Inspire ICE and, as I mentioned, Damon). The difference between customized Insignia and Insignia using stock brackets is the third-order customization (torque) that is engineered into the customized brackets. This difference saves considerable treatment time and effort over using a "best fit torque" stock appliance. Having treated with both customized Insignia SL and Insignia using stock Damon brackets, I can attest to the superior value of the customized appliances.

Case Study: Capitalizing on the Smile Arc1 Function

Treatment Summary

Crowding and full CL II correction with early light elastics. Treated in 11 months; seven treatment visits. No repositions. Wire adjustment at one appointment. (Figs. 3a-3b).

Melissa presented with a Class II malocclusion and significant crowding (Fig. 6a). The treatment plan called for full fixed customized Insignia SL appliances, bite turbos and early, light Class II elastics. With her crowding unraveled after just six months of treatment, Melissa's malocclusion over-corrected to a mild Class III. This phenomenon clearly demonstrates the power of early, light elastics when used in conjunction with disarticulation and Damon System mechanics with customized Insignia SL brackets. By switching to light Class III elastics (nighttime only), she was solidly occluding in Class I position by the next visit and was ready for finishing.

The Insignia smile arc function allows clinicians to design the curve of the upper anteriors to match the patient's lower lip contour with a click of the mouse. As Melissa's treatment progressed, I felt that her smile arc needed to be slightly deeper than I had planned. Repositioning the upper anterior brackets would have been the preferred solution but the logistics of providing treatment from 3,000 miles away made a wire adjustment the favored protocol in this situation. You can see from her final records the pleasing result (Fig. 6b). After Melissa completed treatment, I analyzed her setup in the Approver software to determine how I might have planned her smile arc to create the most pleasing end result. Figure 3a represents Melissa's original setup. Had I set up her case with the smile arc shown in Figure 3b, no wire adjustment would have been necessary.

Conclusion

Here are the primary things I have come to value over the past three years of working with customized Insignia SL:
  1. Computer-assisted diagnostics and treatment planning allows me to "begin with the end in sight" and finish my cases with the same high quality as stock Damon brackets, but faster and more easily. The fact that I estimated 17.5 months for the patients in the clinical evaluation and treated them in an average of 12.5 months was enough evidence for me to begin treating most of my patients with customized Insignia SL.
  2. Insignia provides me with enhanced clinical efficiency. From the initial bonding appointment to the completion of treatment, having the custom appliances specifically engineered to reflect the patient's anatomy drives tooth movement directly to the desired final occlusion, which means fewer adjustments along the way. This efficiency is based on a combination of: 1) creating an ideal final occlusion in the Approver software, 2) quickly and accurately placing the brackets the first time with the precision placement gauges, 3) managing progressive treatment using the five custom-designed Insignia archwires and 4) improved torque delivery from the customized torques designed into each bracket.
  3. Customized Insignia SL has helped me reduce treatment time by more than 20 percent (versus Insignia using stock Damon appliances) and bracket repositioning by 50 percent.
  4. Computerized orthodontics does not take the orthodontist out of the treatment process. Just as today's most technologically advanced fighter jets require an experienced pilot to manage its systems, the orthodontist must still provide clinical oversight to manage each case effectively. What I've realized is that Insignia combined with my clinical expertise yields better results than either of us can provide alone.

Reprinted with permission from Ormco Corporation. Clinical Impressions, Vol. 19, No. 1, Feb 2013, www.ormco.com/ci

References
  1. Sarver, D. Soft-tissue based diagnostic and treatment planning. Clinical Impressions, Vol. 14, No. 1, 2006: 21-26.
  2. Orbit Oral/Maxillofacial Imaging and Diagnostic Services, Newport Beach, CA
Author's Bio
Dr. Jeff Kozlowski is world renowned for his unique perspective on quality orthodontic treatment results and clinical efficiency. An internationally sought-after lecturer, he has presented all over the world on topics including digital orthodontics, facial aesthetics, efficient early treatment, orthodontic treatment mechanics and clinical efficiency. Dr. Kozlowski graduated with a bachelor's degree in economics from Syracuse University prior to receiving his DDS and orthodontic specialty certificate from the State University of New York at Buffalo. He has been published in numerous orthodontic journals. An avid cyclist and endurance athlete, he has completed the Ironman Triathlon five times and the grueling Mt. Washington Bicycle Hill Climb 10 times. Dr. Kozlowski has practices in New London and East Lyme, Connecticut, where he lives with his wife, Amy, a pediatric dentist, and their two children.
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