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Unparalleled Accuracy by Dr. Bryan Lockhart

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Categories: Orthodontics;
Unparalleled Accuracy 

Using digital treatment planning and custom appliances to reduce the chance of operator error

by Dr. Bryan Lockhart

The upsurge of technology in the orthodontic profession has armed orthodontists with an amazing gift. When used properly, digital technology can provide huge advantages on multiple fronts, including digital treatment planning with custom appliances such as custom fixed appliances, clear aligners or custom lingual appliances, as well as the accompanying indirect bonding process. Digital treatment planning gives orthodontists the ability to accurately design and set up cases, and the indirect bonding process is how we accurately take what we’ve done on the computer screen and translate it to our patients.

A digital platform allows for an intricate diagnosis as well as a detailed treatment plan. The ability to examine records to confirm findings or discover new information that hadn’t been found during the clinical exam is powerful. Bolton analysis, pre- and postocclusal contact measurements, and symmetry analysis are just a few of the diagnostic tools at our disposal.


Sights and sites unseen
In regard to fixed appliances, I’d like to introduce a new phrase to the orthodontic community: operator eye bias, which refers to an orthodontic professional’s inability to accurately place brackets on certain teeth because of visual miscues. This most commonly occurs on mandibular first premolars and maxillary laterals; for me, mandibular cuspids are my kryptonite.

Operator eye bias can’t be avoided with analog or digital indirect bonding setups that require manual positioning of brackets, because although we can manipulate the physical or digital models, what our eyes see and where our brains tell us to place the bracket don’t always coincide. Instead, software that allows the orthodontist to focus on final tooth position and not bracket placement is needed. Orthodontists are great at knowing where the teeth should be, and having software with an algorithm to determine the bracket position is key.

Treating an orthodontic case with a digital custom appliance also forces us to do a thorough diagnosis and treatment plan up front. Often, we have a general idea of what we want to do, but are then reactive throughout treatment, making a ton of microdecisions at each adjustment appointment. This works out well for most cases but can be problematic because we may tread in the wrong direction and pivot into a new plan in the middle of treatment, leading to an increase in treatment time, more visits or, worst-case scenario, an unfavorable outcome. Because there is some sort of an initial submission form needed with digital custom appliances, we’re forced to consider all of the treatment objectives and goals up front. This is extremely beneficial from the perspective of preparing cases for success before the start of treatment.


Indirect bonding choices
Indirect bonding has been relevant in our field for many decades. There are myriad techniques and even more opinions about it! However, when done properly, indirect bonding provides a wonderful conduit to transfer what has been digitally planned onto the patient. Without it, all we have is a nice setup on a computer screen.

The fabrication of indirect bonding jigs is an important part of the process. All indirect bonding materials and protocols are not created equal; the choice to make them in-office or rely on third-party fabrication, and manual versus digital, are also factors to be mindful of.
  • Some protocols call for the brackets to be placed on models and the indirect bonding trays fabricated over the brackets.
  • Some require a model with an indirect bonding tray fabricated over the models, and 3D-printed brackets then placed in the basket well of the indirect bonding tray.
  • And some indirect trays can be 3D-printed directly and then the brackets loaded.
Whichever option you choose, just be mindful of accuracy of the transfer jigs and the time and materials needed!


Case study
The treatment for a 29-year-old patient illustrates many advantages of a digital treatment planning platform and a custom appliance. The patient had a Class II skeletal and dental relationship, a gummy smile, noncoincident midlines, a deep bite, a missing mandibular left second premolar and a restored #19 with oversized crown (Figs. 1–3). The patient presented with excessive gingival display and an uncoordinated smile arc (Fig. 4) because of an iatrogenic dental cant, which had been caused by a detorqued maxillary left central and lateral incisors with relative extrusion. (The unwanted torquing had been caused by her maxillary fixed retainer.)
Digital treatment planning
Fig. 1: Initial full composite photographs.
Digital treatment planning
Fig. 2: Initial panoramic radiograph.
Digital treatment planning
Fig. 3: Initial cephalometric radiograph.
Digital treatment planning
Fig. 4: Initial smiling extraoral photograph reveals excessive gingival display and uneven gingival zeniths.


The treatment plan involved orthodontically leveling the patient’s lower arch to reduce the deep bite, aligning her teeth and correcting the dental cant. Her increased overjet and excessive gingival display would be corrected with orthognathic surgery. The LightPlan digital setup from LightForce (Fig. 5) shows the proposed alignment, overbite correction and the torque differential between the maxillary right and left incisors. Fig. 6 shows the proposed final occlusion.
Digital treatment planning
Fig. 5: Digital treatment plan.
Digital treatment planning
Fig. 6: LightPlan simulation of the proposed final occlusion.


The patient’s prescription was custom (Fig. 7), with a slot size of 0.020 by 0.025 inches. The custom prescription was helpful because the patient’s maxillary incisors had different torque requirements; the 0.020-inch slot was chosen so I could progress to a full-sized wire (0.019 by 0.025 inches) more quickly to get full torque expression. Initial bonding (Fig. 8) involved 3D-printed indirect bonding trays to deliver what was digitally planned to the patient.
Digital treatment planning
Fig. 7: Custom prescription values.
Digital treatment planning
Fig. 8: Initial bonding illustrating the accuracy of indirect bonding.


After 10 months of treatment, the patient was ready for surgery with surgical hooks placed (Fig. 9). Her teeth were aligned well, the lower arch leveled and arches coordinated. The proposed surgical plan involved a maxillary impaction and mandibular counterclockwise rotation (Figs. 10 and 11).
Digital treatment planning
Fig. 9: Presurgical composite.
Digital treatment planning
Fig. 10: Proposed orthographic surgery movements—maxillary impaction.
Digital treatment planning
Fig. 11: Proposed orthographic surgery movements—mandibular advancement and counterclockwise rotation.

One month after surgery (Fig. 12), the patient presented with a nice, stable occlusion and ideal overbite and overjet. The short recovery time is a nod to the oral surgeon, but also to a well-decompensated case with coordinated arches. The importance of this is sometimes undervalued by orthodontists.
Digital treatment planning
Fig. 12: Postsurgical composite at first appointment after orthognathic surgery.

When it comes to the releasing of orthodontic patients back to the orthodontist, a few factors come into play. The first is the healing process and the presence or absence of any surgical complications, which is out of the orthodontist’s control. The second factor, however, is completely in our control, and that is coordinated arches.

Presurgical orthodontic treatment can mean the difference between a patient being released back to the orthodontist in one month versus six months. Well-aligned, coordinated arches will allow the oral surgeon to feel confident in their surgical outcome, will require less postsurgical bite coordination and, subsequently, a quicker release back to the orthodontist. Contrarily, not setting the oral surgeon up for success (i.e. uncoordinated arches, malalignment, torque discrepancies, etc.) can lead to multiple weeks of different elastic patterns and postoperative checks until the oral surgeon believes the case is presentable enough to return the patient to the orthodontist. This can adversely affect the overall treatment time of a case—and having done an orthodontic/orthognathic surgical fellowship, I’ve seen this happen firsthand.

This case finished seven months later (Fig. 13), with overall treatment time of 18 months. Final radiographs are shown in Figs. 14 and 15 and regional superimpositions in Figs. 16 and 17. The postsurgical orthodontic treatment consisted of elastics wear to settle the patient’s bite and final space closure.
Digital treatment planning
Fig. 13: Final treatment composite.
Digital treatment planning
Fig. 14: Final radiograph.
Digital treatment planning
Fig. 15: Final radiograph.
Digital treatment planning
Fig. 16: Regional superimpositions.
Digital treatment planning
Fig. 17: Regional superimpositions.


All of our treatment goals were met: The patient’s teeth were aligned, she had ideal overbite and overjet, and her dental cant and the differential torque of her maxillary incisors were corrected. The orthognathic surgery reduced her overjet and alleviated her gummy smile (Figs. 18 and 19).
Digital treatment planning
Fig. 18: Pre- and posttreatment overjet.
Digital treatment planning
Fig. 19: Pre- and posttreatment extraoral photo—gummy smile correction after surgery


Lastly, a highlight of a custom appliance is the ability to control the movement of each individual tooth and provide its own customized tip and torque. This is depicted in Fig. 20, where the custom prescription for her maxillary incisors allowed for efficient treatment without the need to detail with repositions and/or wire bending for torque expression.
Digital treatment planning
Fig. 20: Pre- and posttreatment torque changes of the maxillary incisors—differential torque changes accomplished with a custom prescription.

Conclusion
My argument in favor of custom appliances has never been about obtaining results that couldn’t have been achieved with noncustom appliances. With time and a great detailing protocol, great orthodontic results are absolutely doable with most noncustom appliances on the market today.

I see the biggest benefit from custom appliances in both the reduced treatment time needed to get similar results and also the consistency of good clinical outcomes. We’ve all had cases that treated out well and in an extremely efficient manner when bracket placement was accurate, the patient was compliant and took care of their appliances and good growth was on our side! However, we should not judge our mechanics and treatment efficiency on the outliers, but rather the work we consistently produce the majority of the time.

Digital treatment planning allows for a detailed diagnosis and treatment plan, and the indirect bonding process allows for that information to be replicated in the patient’s mouth. When combined with a custom appliance, this creates a pathway for efficient treatment in the overwhelming majority of cases.

We should all strive to get the best clinical outcomes possible in the most efficient way possible. For me, digital custom appliances are how I do both. Let’s continue to push the profession forward!

Author Bio
Dr. Bryan Lockhart Dr. Bryan Lockhart is a board-certified orthodontist with two practices in Charlotte, North Carolina, where he practices with his wife and fellow orthodontist, Dr. Lauren Rennick Lockhart. He attended dental school at the University of North Carolina at Chapel Hill and earned a certificate in orthodontics from Jacksonville (Florida) University. A frequent speaker on digital orthodontics, Lockhart also has developed his own clear aligner brand, Dualine, and holds patents for an orthognathic device and a practice management software program. He is also a member of the LightForce clinical executive board.

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