What’s the Hurry? by Dr. Neil Warshawsky

Reducing treatment time (and office visits) with manual osteoperforation and high-frequency vibration technology

by Dr. Neil Warshawsky

We live in a fast-paced world. When I started my orthodontic practice nearly 30 years ago, I never would have guessed that direct-to-consumer concepts would have patients bypass my office altogether. It’s becoming painfully clear that patients want faster treatments with fewer office visits. Now with the coronavirus, fewer visits are a necessity.

I have learned to embrace new technologies and use them to grow my practice. I enjoy practicing in a “boutique” fashion—albeit on a big-box-store level, because we have multiple offices—and try hard to give people what they need. This requires stocking more than one type of bracket to address a multitude of different issues. I changed my approach to practice patient-centric care and try to satisfy what the patient wants, not just what I think they need.

Some patients are not sure what they want or need. Many patients now walk into our free consults armed with their smartphones and are quick to pull up a photo of their smile from 20 years ago or the smile of a favorite celebrity they stalk online and innocently request to have their smile “look like this.” The approach to satisfying this patient will vary based on whether they are Gen Zers (born 1997–present), millennials (1981–1996), Gen Xers (1965–1980) or baby boomers (1946–1964).

We now base our recommended treatment parameters on five factors: looks, cost, comfort, speed and lifestyle. Looks cover what your appliance will look like—fixed brackets versus aligners, labial versus lingual, clear ceramic versus metal. Comfort covers aligners versus fixed brackets, but also covers low-profile bracket versus a standard profile, or stock brackets versus custom-made appliances. I’ve found that patients get to the end of their treatment quicker when using custom appliances.

Several years ago, we started offering speed—specifically, augmented procedures, mechanics or appliances that help reduce the treatment. Through a combination of custom appliances, custom physiology, fixed anchorage, mapped trauma, surgically facilitated orthodontic treatment, MOPs, soft-pulse vibration, etc., we learned that we could get orthodontic results quicker with no deleterious effects. It was fascinating, actually, because for the first time, I could dictate how long it would take to complete an entire case.

Some of you may say, “So what? I can get a case to treat out in a reasonable amount of time,” and I agree. The problem lies in the patient’s generation, which dictates whether this is an acceptable answer to them. The millennial generation has caused the greatest impact and change to my practice. They are the ones having babies right now.

Speaking as one of the youngest baby boomers, or oldest Gen Xer, my generation still enjoys the art of conversation. I still see the use for an old-fashioned trip to a bricks-and-mortar store where you get to lose yourself and shop for something that you most likely don’t need. It’s one of those guilty pleasures in life that I still enjoy; it’s almost like a reward after fulfilling a difficult job or task—or in my case, completing a difficult lecture or paper. Not for millennials. No way. Why would they go to a physical store when they own smartphones? All they need to do is go to Amazon, and what they want could get delivered that day.

I scoffed the first time I heard someone say they’d ordered groceries online and had them delivered to their home. But my friends and I recently used a service on a ski trip where we pre-shopped our groceries and had them delivered and placed in the refrigerator before we arrived at the destination. If you’re away for only a few days, how convenient is it to not have to waste the time to drive to the store, shop for the groceries, then come home and put them away. Yes, like a moth being drawn to a bug zapper at dusk, even I, a self-proclaimed boomer, love the convenience of a personal shopper from time to time.

A frequent challenge I see in our offices is a patient who comes in for a second opinion for clear aligner therapy. The sexiness of its simplicity, the ability to remove it and its superior aesthetics draw in millennials. Of course, as an orthodontist, I think it is difficult, because it’s not on the teeth 24/7, patients can remove it whenever they want and certain moves, such as vertical extrusion or severe rotations, historically do poorly in aligners. I now offer three additional treatment protocols in response to the “live in the moment” millennial generation. We offer conventional therapy, as we always have. Whether it is fixed or removable I do not care, but when someone is severely crowded on one arch and less so on the other arch, we consider combination therapy. One arch may be aligners and the second arch may be in fixed appliances.

Our second alternative treatment is a hybrid approach, where we place fixed appliances, then remove them after a few months. The advantage of a hybrid case is to mitigate the worst issues so that they are now treatable by clear aligner therapy. After all, my goal is to treat out a case in 18 months or less whenever I can. That can be challenging if it is only aligners and the crowding is severe.

Occasionally, I will have a case that has a unique objective such as opening an implant space, uprighting a molar that is mesially dumped or correcting a tooth that is in crossbite. These are all integral to the successful architecture of a stabilized well-treated case. If we mix the concept of fixed and removable appliances together, then it is referred to as a sequential treatment plan. These are the tools of the new world. Along with what I refer to as augmentive tools, such as MOPs and vibration, we are changing the landscape of conventional orthodontics and satisfying the unapologetic requests of those whose cases must be done faster and in fewer visits.

Case 1

A 24-year-old patient was told he needed to have orthognathic surgery because of asymmetrical growth of the mandible. I was the third opinion, and he sought me out specifically because I was likely to give him an option that did not involve surgery. As we discussed his case, he made it clear to me that surgery was off the table. He also did not care if things were perfect or not. That was important to know, because I was not sure how far I could get him without surgery.

He presented with a bimaxillary crossbite of the molars, a significant midline deviation of 3mm to his left of the lower teeth, and an edge-to-edge anterior bite that caused his teeth to chip (Figs. 1–3). Our plan initially involved using a NiTi palate expander for the upper arch to jump the molar crossbite, MOPs of the maxillary buccal cortex to soften the bone around the molars, and extraction of the lower right first premolar, followed by fixed mechanics for a short time to start space closure.

The patient had already had fixed appliances once, and still had his fixed retainers bonded to his teeth. Although I treatment-planned fixed mechanics on the lower arch, my intentions were to use it for about 100 days. He did not want any fixed mechanics, so I was limited in what I could get him to agree to. Histologically, this would wake up the teeth and begin the space closure.

Then, I would remove all of the fixed mechanics, take records for clear aligner therapy and complete the case in aligners with a VPro+ (Propel Orthodontics) to deliver daily high-frequency vibration. I planned to treat the midline with elastics, knowing that the midline would start to the left and to the right to get the best fit of the teeth without exacerbating the root resorption on the lower right premolar.

One thing to note is the foreshortening of the roots from the first treatment. To minimize tooth movement and maximize tooth correction, I decided to remove #28. Although #29 had more root resorption, I felt #29 ultimately would experience less movement if I extracted #28. My hope was that removing #28 would expose #29 to less of an opportunity for root resorption. I was in favor of clear aligner therapy. I can increase my aligner case selection when I add augmentive tools such as MOPs and VPro. The patient needed fewer office visits because of his restrictive schedule, so it was the perfect match.

After three months, we were ready to remove the expander (Fig. 4) and braces (Fig. 5), take full diagnostic records for clear aligner therapy and plan a significant change in occlusion for this challenging problem. There was a significant change in the transverse relationship of the molar teeth after the NiTi expander with MOPs. No further damage was noted to the permanent teeth.

The prediction indicated a significant change in torque of the anterior teeth, as well as a bodily movement of multiple teeth to control a change in the midline. I used the Clarity Aligner system from 3M Oral Care, because I thought the longer tray design and stiffer material would help me maintain control as I uprighted the lower teeth and translated them to the right to close an extraction space. The case required 48 trays and two refinements. Refinements were determined with the progress checking tool (Fig. 6). The scan data was used to steer the case, keep the movement efficient and minimize roundtripping of the teeth.

The overlay of the teeth at Stage 48 (Fig. 7) shows how successful the extraction space closure was. As predicted, the midline moved almost 4mm to the right as the overbite and overjet were created. The progress scan report was utilized to build a few additional aligners to upright the midline further and stabilize the anterior occlusion.

Photos were taken on March 13 (Fig. 8). He had one remaining aligner, but I haven’t seen him because of the pandemic. You be the judge: Is the crossbite resolved? Have we created overbite and overjet? I did not plan to have the midlines coincident, because of the unilateral extraction, but it appears the case will finish close to what we predicted. It’s important to note that no additional root resorption was observed in this case. Of course, when I can schedule him, I will remove attachments, perform an equilibration and obtain full diagnostic records. I expect that the case will be completed when he returns to the office.

Case 2

The second case follows a healthy 24-year-old patient who proposed to one of my previous patients. Similar to the last case, this patient had orthodontic treatment as an adolescent and still had his lower fixed retainer. His fiancée wanted to see if I could improve his smile before the wedding.

He was a Class I malocclusion with a complex crossbite and a narrow maxilla (Figs. 9–12). I planned to treat him with fixed self-ligating appliances and treat the buccal segments with MOPs. This only takes me a few minutes with compounded topical. I then used overexpanded archwires to jump the complex crossbite. To heighten the responsiveness of the teeth, I had the patient use a VPro+ high-frequency vibration device for five minutes a day before bedtime. (This also alleviates the discomfort.)

Between loosening the teeth and decreasing bone density with the augmentive vibration device, softening the buccal bone with MOPs, then applying crisscross elastics daily to broaden the upper dental arch, I thought I could widen the upper dental arch without the help of an expander or surgery. This was a key factor for my patient, because he was relatively new in his job and could not take time off.

In addition to proclining the maxillary teeth, I used interproximal reduction and AP elastics to create the shape of the new upper dental arch form and stabilize the occlusion. I used MOPs on the upper posterior teeth within the first month of applying the braces (Fig. 13). Affected zones went from the mesial of the upper canine to the mesial of the second molar on both sides. Two to three perforations were created between the roots of the affected teeth. Total chair time was approximately 10 minutes.

After three months, the teeth were visibly decompensating, and the bite appeared to open, because the palatal cusp tips had traumatic contact on the opposing teeth (Fig. 14).

Around Month 5, I got into rectangular NiTi wires and started to run heavy crisscross elastics to further develop the transverse maxillary width (Fig. 15). By Month 11, the midlines were addressed, the anterior open bite was noted and I switched to Class III vertical elastics to stabilize the case. I finished more than a month before the wedding (Fig. 16). Changes were significant, his occlusion was stabilized, and the teeth were not damaged. Final alignment shows that we achieved our goals and did not cause any permanent damage to the teeth (Figs. 17 and 18).

Case 3

This patient called me several years after I had treated him with non-extraction as a teenager (Fig. 19). He’d had a vertical growth tendency but looked exactly like his parents—neither of whom had extractions associated with their orthodontic treatment—so I was unable to convince them that removing teeth would make sense.

About eight or nine months ago, the patient called me up to discuss what was going on. He now lived in San Francisco working for a tech startup and was starting to have trouble chewing but he wasn’t sure why, so he made an appointment to see a local orthodontist.

The doctor told him he had an anterior open bite and jaw surgery was the only way to correct it. My patient didn’t understand how this could have happened and didn’t believe surgery was the only solution. His parents still lived in Chicago, so he made arrangements to come home to get my take on what I thought was going on with his occlusion. When the patient arrived I took a cone beam and looked at his growth pattern (Figs. 20 and 21).

What I found was no different from what I saw when he was an adolescent: He still had the same vertical growth pattern. He did not open up any more vertically than when I saw him as a teen. I do believe that he experienced late-onset mandibular growth; I saw a mild Class III malocclusion with an edge-to-edge anterior bite. Most importantly, I did not believe that this had to be a surgical solution. His joints were not quite seated, and he had no symptoms.

After discussing his situation, I suggested he try our in-office digital workflow. Because he lived out of town, we could scan his teeth and build some custom removable aligners. I asked that he wear Class III elastics with the trays to correct the AP overgrowth. I would likely need to see him a few times, but I could monitor his progress via telemonitoring.

The clincher for him was that I offered a same-day start. I proposed to scan him, design his case and build the first few trays that day. I figured if I could place attachments and deliver the first few weeks’ worth of trays while he was with me, I could mail out the remaining trays as we completed them.

We used 3Shape to scan his teeth and the tooth alignment was engineered in uLab. Models were printed on a SprintRay Pro and our work process was tracked from start to finish with EasyRx. Our aligners are produced on Drufomat scans from Dentsply using Bay Materials’ Zendura FLX. Because the patient lives 3,000 miles away, he automatically gets a VPro+ to help the aligners to fit and seat better. He checked in biweekly via cellphone (Fig. 22).

It may sound like a lot, but he was only in the chair for 30 minutes to examine him and take records. It took 20 minutes to place buttons for elastics and deliver the aligners.

He returned to the office in approximately four months and I was very pleased with the progress (Fig. 23). I found a very compliant patient and a closed open bite. The anterior teeth were in occlusion, but the right buccal segment could be further closed and the overbite was still a bit on the shallow side. To be as accurate as possible, I rescanned his teeth to build the final aligner stages. We built the first three stages again, delivered them the same day and confirmed everything fit well. We mailed him the remaining stages.

For less than four months of effort, not only were we successful in helping him out, we showed that jaw surgery was not the only way to resolve his issue (Fig. 24). The patient will also use his VPro+ in retention to make sure his retainer fits properly.

Conclusion

What’s so important to take out of these cases is that patients want to be done in a hurry with fewer office visits. In the past, I couldn’t offer this for more advanced cases; now, with MOPs and vibration to help patients stay on track, I’m confident that I can. Teledentistry, in-office aligners and vibration are here to stay.

I started this article when I went skiing with my buddies and, honestly, I forgot about turning it in. Four weeks later, the COVID-19 pandemic turned our world upside-down and put our economy and way of life on hold. This is an opportunity to reinvent yourself.

Working at the University of Illinois Craniofacial Center, I have a firsthand view of the damage the virus is doing and its catastrophic pattern of disbursement and spread. How bizarre to think that teledentistry and fewer office visits would become a front-and-center concept because of the pandemic. And it’s one more reason to look at MOPs and soft-pulse vibration: Keeping your cases on track from the beginning will help your business stay viable when traditional economic models are failing. Using technology kept my aligners fitting and tracking better and allowed patients to check in with me so that I could intervene when I deemed it necessary.

Whether you feel the need for speed, or as in more recent days you can’t see your patients, I find these technologies help me to help my patients to get it straight!