Special Section: Startup Showcase

Categories: Orthodontics;
Special Section: Startup Showcase 

Featuring 3 new contenders among fixed-orthodontics treatment options

Despite the strong orthodontic market shift towards clear aligners over the past 20 years, are we beginning to see a fixed-orthodontic treatment renaissance?

Dr. Brandon Owen of KLOwen, Dr. John Pham of InBrace and Dr. Alfred Griffin III of LightForce are orthodontists who would argue yes. Through their own blood, sweat and tears, they have each lifted startup orthodontic companies, backed by truly innovative technologies, to serve and advance their orthodontic colleagues.

I hope you enjoy their discussion and cases presented here.

— Dr. Chad Foster, editorial director

Compliance-Free Options

InBrace’s new category of behind-the-teeth treatment enables automated tooth movement in all six degrees of freedom—and is customizable
— by Dr. John Pham


A 20-year-old patient presented with the chief complaint of upper canine in crossbite and crowding. Although she wanted straighter teeth, she would have gone untreated rather than put in the work of wearing plastic aligners or have a visible appliance placed on the front of her teeth.

The patient had no significant medical or dental history, and no contraindications to orthodontic treatment. Extraoral examination revealed symmetric facial proportions and a harmonious lower profile with well positioned upper and lower lips.

Intraoral examination (Fig. 1) revealed a minor Class II relationship with normal overbite, 2.5 mm of crowding in the mandibular arch and 4 mm of crowding in the maxillary arch. UL3 was in lingual crossbite with LL3, causing a functional mandibular shift to the left side. Upper midline was  coincident but not parallel to the facial midline. Lower midline deviated to the left by 2 mm. TMJ examination was noncontributory. The cephalometric analysis indicated a mild skeletal Class II with mesofacial growth pattern.

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Fig. 1: Initial records.

Main problems to be addressed were:
1. Upper and lower crowding.
2. UL3 lingually positioned in crossbite, which was affecting smile aesthetics.
3. Dental Class II relationship.
4. Midline discrepancy.
5. Upper midline slanted to the right. 

Patient records and intraoral scan (Fig. 2a) were used to generate the InBrace Smile Design (Fig. 2b). The InBrace appliance was bonded using 3D-printed indirect bonding trays. At the initial bonding appointment (Fig. 3a), bite turbos were bonded on the palatal cusps of the maxillary second molars to avoid heavy bracket interference in occlusion, and Smartwire 1 was engaged in all brackets except UR3, which was significantly rotated (Fig. 3b). Once engaged, the Smartwire Intelligent Programmed (IP) Loops in the interproximal regions were then activated to move teeth in all six degrees of freedom, including opening space to more easily engage UR3 and derotate UL3.

In two months, the alignment of the upper teeth had improved significantly, and space had been  created, which allowed the UR3 bracket to be engaged and UL3 to be derotated more easily (Fig. 3c). At five months, alignment had been completed, and the IP Loops had closed the space that  had opened to aid with derotation of UL3 (Fig. 3d). Smartwire 2 was engaged, and clear buttons were bonded to start Class II box elastics (3/16 inch, 4.5 oz.) on both sides. When Class I  relationship was achieved, Digital Enhancement Smartwires were engaged for final detailing (Fig. 3e). After 14 months of active treatment, the case was debonded (Fig. 3f).

Showcase_fixed orthodontic treatment optionsFigs. 2a, 2b: Initial intraoral scan; InBrace Smile Design.
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Figs. 3a-3f: Treatment progress for the maxillary arch. (3a) Initial. (3b) After bonding. (3c) After two months. (3d) After five months. (3e) After 12 months. (3f) Final.

For the lower arch (Fig. 4a), Smartwire 1 was engaged in all brackets at the initial bonding appointment (Fig. 4b). Two months later, the alignment had significantly improved, allowing for Smartwire 2 engagement (Fig. 4c). At five months, Smartwire 2A, which has a lower anterior straight-wire section, was used to finish the lower anterior alignment and to increase rigidity to better support Class II elastics (Fig. 4d). When Class I relationship was achieved, Digital  Enhancement Smartwires were used for final detailing (Fig. 4e). A fixed lower 3–3 retainer was placed at debond.
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Figs. 4a-4f: Treatment progress for the mandibular arch. (4a) Initial. (4b) After bonding. (4c) After two months. (4d) After five months. (4e) After 12 months. (4f) Final.

This case was treated in 14 months and seven appointments; Fig. 5 shows the patient’s final records. Notably, this patient couldn’t be seen for an appointment for four months because of COVID-19, but treatment still was able to progress as planned because of the programmed  automation with the InBrace system.

On comparison of pretreatment and posttreatment records (Fig. 6), all treatment objectives were  achieved where:
1. Upper and lower crowding was resolved.
2. UL3 crossbite was resolved.
3. Class I relationship was achieved.
4. Coincident midlines were achieved.
5. Upper midline was parallel with the facial midline.

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Fig. 5: Final records.
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Figs. 6a, 6b: Comparing initial and final treatment.

Figs. 7a and 7b show pretreatment and posttreatment panoramic radiographs. 

Overall, this case illustrated that the InBrace system using PNM allows for aesthetic, predictable,  efficient and compliance-free treatment with minimal clinician intervention, because of the automation built into the programmed Smartwires. 

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Figs. 7a, 7b: Initial and final panoramic radiographs.

Case courtesy of Dr. Andre Weissheimer

About InBrace

Research shows three in four people need orthodontic treatment, yet in the United States alone, less than 2.5% of those indicated follow through. Why?

Many consumers are not starting treatment because orthodontists are not offering a treatment option that fits their lifestyle—they’re either too visible with metal/clear braces or require too much compliance with plastic aligners. New categories of orthodontic treatment in the past grew our profession by challenging the status quo and introducing stepwise innovation leading to stepwise growth in our market.

InBrace, a new category of behind-the-teeth orthodontic treatment, developed a way of moving teeth using programmed nonsliding mechanics (PNM) which enables autonomous tooth movement in all six degrees of freedom, including opening and closing spaces, simultaneously and automatically from day one. PNM is made possible by a programmed Smartwire that is fully customized for each patient’s unique smile.

The InBrace appliance design, combined with the benefits of PNM, enables orthodontists to leverage all the efficiency upsides of customized orthodontic treatment with the added benefit of offering a differentiated behind-the-teeth option that is delegable to assistants.

Analog-to-Digital Conversion

KLOwen’s custom, digital straight-wire solution
— by Dr. Brandon Owen


This case, submitted by KLOwen scientific advisor Dr. David Richter, demonstrates a clinically excellent finish of a Class II (right and left) with significant space on top and mild and lower incisor crowding. The case completed in 14 months with 11 appointments.

The digital setup matched the straightwire alignment perfectly, but the maxillary incisors were left-rotated out on the distal, requiring three detailing appointments. This case would have finished faster with even fewer appointments had those positions been caught on the digital setup.

Richter reported his typical cases average only one detailing appointment, and says this case would have been a two-year case if treated conventionally in his office.
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Fig. 1a
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Fig. 1b
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Fig. 1c

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Fig. 1f
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Fig. 1g
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Fig. 1h
Figs. 1a-1h: Initial layout, Oct. 15, 2019. Patient was bonded, and placed 14 NiTi UL and buildups on the L7s,on Jan. 10, 2020.

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Fig. 2: Bracket prescription.

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Fig. 3a
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Fig. 3b
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Fig. 3c
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Fig. 3d
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Fig. 3e

Figs. 3a-e: Nine-month progress shot. Forsus worn from May 29 to Sept. 8, 2020.

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Fig. 4a
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Fig. 4b
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Fig. 4c

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Fig. 4d
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Fig. 4e
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Fig. 4f
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Figs. 4a-h: Patient debond, March 2021.

About KLOwen

During the past several decades, orthodontic practices have increasingly recognized the inherent efficiencies of the digital workflow for aligners. As a result, orthodontists have made
significant investments in digital equipment such as scanners and 3D printers, in digital workflow education for the doctor and staff, and in aligner lab fees. These investments have increased practice efficiencies and patient experience, but data shows that fixed braces are still the appliance of choice for up to 70% of patients in orthodontic offices.

“If you put the braces in the right place, the case treats itself,” a mantra I’ve heard myriad times, is false. For 10 years, I explored digital solutions to perfect bracket positioning and unlock the benefits of true straight-wire mechanics. After trying 16 unique digital braces systems that allowed for measurement down to 0.01 millimeter, I discovered that digital indirect bonding (IDB) and perfect bracket positioning does not allow straight-wire treatment. While ideal bracket positioning did allow me to get the second order where it needed to be, this technology alone lacks control in first and third order. Also, I still needed to make second-order adjustments to align marginal ridges when the real issue was inadequate third-order control.

Digital on its own is not enough; it gets us to only 33%, even with perfect with bracket positioning. A straight-wire solution must be digital and custom.

Imagine if aligners gave us only a single prescription (MBT, Damon, Andrews, etc.) for every case: Teeth would inevitably end up in an incorrect position because a one-size-fits-all system
does not truly fit anyone perfectly. With aligners, the optimal tooth position for the individual patient dictates the prescription as recognized through digital technology. Because of these
experiences, we know it is digital bracket placement with the custom prescription that contributes to success.

The digital custom braces that I tried during my first years in practice taught me much about where to look for optimal solutions. On the surface, it seems like those modalities should have already replaced conventional analog bracket systems. However, there were critical roadblocks with early custom digital solutions:

  • The capital and labor intensity to manufacture these appliances created a prohibitively expensive price tag (typically $700+ more than conventional twin brackets).
  • The workflow required a considerable time to fabricate and deliver to offices (often four to eight weeks).
  • Many systems did not adequately support slot-filling mechanics and required significant wire bending or repositioning to achieve optimal clinical results.
The key takeaways as I moved to develop the KLOwen Custom Braces System were:
  • We need to fill the slot with a custom prescription for excellent, efficient results.
  • The IDB trays must be accurate.
  • Less-expensive solutions with faster turnaround are imperative for scale in our practice.
The system offers 100% custom positioning of each tooth through 27 brackets with variations in torque and in thickness. Software selects the best-fit bracket (first and third order) for each tooth once the doctor has positioned the teeth in the program; the second order is handled by the IDB tray. If seven degrees of torque is necessary, a five-degree bracket is selected, and the final two degrees is built into the composite base at the bonding appointment.

The IDB tray allows orthodontists to determine how much adhesive is needed. The first order will always maintain a distance of less than 0.2 mm between the tooth surface and the bracket base. This assures that with proper technique, the debond rate will be on par with direct-bonded cases. The tooth does not know the difference between 0.05 mm thickness of
composite vs. 0.5 mm; it simply reacts to the force applied at the bracket wire interface.

KLOwen offers a custom solution 7–7 (or even 8–8) at a $400 price point (for brackets, full lab service and software) with a two-week turnaround time from lab to office. Knowing the future is in-house digital workflow control, it is also the only digital custom bracket solution that allows practices to bring the printing of the IDB trays in-house and reduce the cost/case to $350. In-house turnaround to patients in less than a week.

The company has several providers who are already implementing in-house printing to realize results for their practices and patients. Same-day starts are possible with KLOwen. If you decide to bring the entire workflow in-office (training an in-house digital technician to do the setup), this custom digital solution can be completed in a few hours at a low price point.— Dr. Brandon Owen


Super Predictible and Customizable

LightForce’s 3D-printed, fully custom and fully digital tooth-moving platform
— by Dr. Alfred Griffin III


Pretreatment diagnosis
Class II malocclusion, Division 1, subdivision right; mandibular functional midline deviation, upper arch mild crowding, lower arch moderate crowding.

Treatment plan objectives
1. Correct Class II sagittal dental relationship of the right side.
2. Achieve facial balance.
3. Upper incisors palatal crown torque to create clearance.
4. Lower incisors torque control to avoid side effect of proclination generated by mandibular advancement device.

Appliance(s) used
LightForce 0.018-inch-slot customized brackets (Fig. 1), indirect bonding; Forsus Class II correction system (3M).

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Fig. 1

Treatment plan notes submitted:
Torque customization in setup:
• L1s and L2s set to –6 degrees.
• U1s set to 16 degrees.
• LR4 4 degrees distal rotation to offset rotation from Forsus arm.

Treatment discussion
Orthodontic correction of a Class II malocclusion can require distalization of molars in certain clinical circumstances, but when asymmetrical mandibular shift occurs, the unilateral mandibular functional advancement is hard to accomplish. 

This case illustrates the use of Light-Force full customized brackets as a precise strategy to avoid typical side effects generated by fixed functional orthopedic appliances such as a Forsus 3M appliance.

Upper and lower incisors’ lack of torque control were anulated with confidence and precision. No wire bending was necessary and treatment was completed in 16.5 months, including three months of no visits because of COVID-19.

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Fig. 2: Initial records
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Fig. 3: Initial records
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Fig. 4: Appointment 1 (Dec. 27, 2019). Brackets and tubes bonded; upper and lower 0.014-inch nickel titanium (NiTi) archwires placed; oral hygiene instructions delivered.
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Fig. 5: Appointment 2 (March 13, 2020). Upper and lower 0.016-by-0.022-inch NiTi archwires placed.
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Fig. 6: Appointment 3 (June 18, 2020). Upper and lower 0.016-by-0.022-inch stainless steel (SS) archwires placed as working wires to close space with sliding mechanics.
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Fig. 7: Appointment 4 (July 31, 2020). Forsus installed; instructions delivered to patient. Patient remains in upper and lower 0.016-by-0.022-inch SS archwires.
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Fig. 8: Appointment 5 (Oct. 23, 2020). Class I achieved; patient remains in upper and lower 0.016-by-0.022-inch SS archwires.
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Fig. 9: Appointment 6 (Dec. 4, 2020). Forsus removed; stepped up to upper and lower 0.017-by-0.025-inch NiTi archwires.
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Fig. 10: Appointment 7 (March 5, 2021). Power chain installed upper and lower.

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Fig. 11: Appointment 8 (April 16, 2021). Debonding, final records.
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Fig .12: Appointment 8 (April 16, 2021). Debonding, final records.

About LightForce

Showcase_fixed orthodontic treatment optionsLightForce Orthodontics' business has doubled in size every quarter for the past three quarters. The company’s top users include Drs. David Sarver, Maz Moshiri, Brian Lockhart and Alexander Waldman.

The momentum is centered around LightForce’s 3D-printed, fully custom and fully digital tooth-moving platform. 3D printing enables an extreme level of customization and predictability, and the company also offers custom indirect bonding trays, custom bite turbos, custom hook placements, an iPhone-based face scanning software to construct smile arc and, most recently, the launch of the translucent 3D-printed bracket pictured at right. (Its first 3D-printed bracket offering is white.)

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