Accelerated orthodontics: Perspectives by Seattle orthodontist, Keith B. Wong

Over the last century, numerous orthodontists have continued to improve the efficiency of the technology employed.  One focus has been to increase the effectiveness of tooth movement in a given amount of time, sometimes referred to as “accelerated orthodontics.”  In the 20th century, most of the breakthroughs in making orthodontic treatment shorter had to do with improvements in either materials (e.g. better alloys for wires) or appliance design (e.g. reducing friction).  More recently, technologies that more directly address the body’s ability to respond to orthodontic force have been available.  Following is a summary of these technologies and comments on their clinical use and effectiveness (based upon both scientific studies and the impressions of Seattle orthodontist, Keith B Wong, DDS, MS):

AcceleDent  (Vibration)

AcceleDent was the first FDA-approved appliance to make orthodontic treatment faster.  The explanation of how it works is that AcceleDent “applies precisely calibrated vibrations called micropulses that transmit through the roots of your teeth to the surrounding bone. This gentle vibration helps increase the cellular activity and speeds the rate in which your teeth can move.”  AcceleDent also claims that there is less discomfort associated with orthodontics when using the device.  My experience with AcceleDent is that it can help Invisalign patients move through their aligners somewhat quicker (due to the vibrational seating of the aligners, thereby making them more active) and it does reduce discomfort, however, the bulk of scientific studies into AcceleDent do not support its ability to accelerate orthodontic movement per se.  For this reason, I do not recommend AcceleDent currently.

OrthoPulse (Photobiomodulation)

OrthoPulse is the first FDA-approved appliance to use light (near-infrared, nIR) to achieve accelerated orthodontics.  The explanation of how it works is that OrthoPulse delivers energy via photons of nIR light to the mitochondria of the bone and tissues  to help create more energy (in the form of ATP) to supply the biological processes involved in orthodontic tooth movement.  It also is claimed to reduce discomfort associated with orthodontics.  In the case of OrthoPulse, studies do consistently show statistically significant and clinically significant increases in the rate of orthodontic tooth movement with both Invisalign and traditional orthodontic appliances.  I have seen this clinically along with apparent reduction of orthodontic discomfort.  I do make OrthoPulse an option for patients that choose to reduce treatment length, however, it is important to note that appliance-based acceleration necessitates consistent daily use (typically 5 minutes per arch with OrthoPulse).  While OrthoPulse works well to move teeth faster in simple, routine, and somewhat challenging cases, when extremely challenging tooth movements are required, I would not depend on OrthoPulse alone.

Periodontally Accelerated Osteogenic Orthodontics (PAOO or aka “Wilckodontics”)

PAOO is a procedure, rather than an appliance, which achieves accelerated orthodontics, although I tend to employ PAOO for its significant effect in improving the volume of bone supporting teeth and the long-term health of the periodontium.  In short, PAOO is a periodontal/oral surgery (done by a periodontist or oral surgeon) to effect biochemical responses from the local tissues that result in significantly accelerating the process of bone remodeling (which is the primary process associated with orthodontics).  During the procedure, plentiful amounts of mineralized matrix is placed where the bone is not currently sufficient to support teeth, then teeth are orthodontically moved into that matrix, which has the effect of transforming it into robust, living bone that supports the newly positioned teeth.  As I mentioned, I use PAOO primarily to augment the periodontal support in order to move teeth into areas that do not have enough bone (for example, cases where facial aestheics prohibit the extraction of teeth but straightening the crowded teeth alone would push them OUTSIDE the existing bone).  In unique cases, we have recommended PAOO for accelatory reasons, but the procedure is more invasive than using an appliance and should be considered thoroughly.

Propel (Microosteoperforation, MOP)

Propel refers to procedure that is performed by the orthodontist (or another practitioner) with a specific device.  It is a localized relative of the PAOO, but on a much smaller scale.  Very small perforations are made through anesthetized gum tissue into the outer plate of the bone that holds the teeth.  The act of perforating the bone results in biochemical response that enhances bone remodeling around each site (to one centimeter in diameter).  The perforation procedure is quick (approximately one minute per perforation) and no stitches are required, thus it is much less invasive than the PAOO.  This enhanced bone remodeling makes tooth movement faster but I prescribe it generally to make large or challenging tooth movements more reliable and predictable.   Especially in adult patients, using the Propel procedure often means the difference between successfully moving the tooth orthodontically versus needing to consider surgical movement of the teeth and bone.

VPro5 (Vibration)

VPro5 is a vibrational accelerating appliance made by Propel.  It vibrates at a higher frequency than AcceleDent, which studies suggest may accelerate tooth movement more effectively, however, Propel markets the VPro5 for aligner seating, discomfort reduction, and to help extend the effective life of the Propel procedure, which is usually 4-6 months.  I have found that the VPro5 does seat aligners and reduce discomfort.  We are now giving them to some patients post-Propel to see if they do seem to extend the effects.  I have not seen any studies addressing this use.

As one can see, there are significant differences between the various approaches to “accelerated orthodontics” and communication with an experienced clinician that has used them is recommended before opting to utilize them.

For more information from the manufacturers/proponents:

AcceleDent     http://acceledent.com/home/

OrthoPulse     http://orthopulse.com/patients/

Wilckodontics     http://www.wilckodontics.com/Consumers/AboutTheProcedure.html

Propel/VPro5     https://propelorthodontics.com/

How long does Invisalign treatment take, and am I, or is my child, a good candidate?

In our practice, Invisalign and traditional treatment with brackets and wires require similar treatment lengths; the total time being dependent upon case complexity.  The key to efficient and excellent treatment with Invisalign is the clinical understanding of Invisalign mechanics, which differ greatly from wire and bracket mechanics.  Most patients, adult and teen, can be effectively treated with Invisalign through the incorporation of advanced Invisalign techniques, the proper sequencing of tooth movement, and, when needed, the limited use of traditional orthodontic auxiliaries.  Many cases that would be difficult to treat with Invisalign alone are hampered by the position of one or two teeth and the corresponding corrective movements that are necessitated.  Often, by utilizing traditional techniques to align these teeth in preparation for Invisalign, an experienced orthodontist can transform the case into one that will allow successful and efficient Invisalign treatment.  Orthodontists skilled in both the use of Invisalign and traditional care can effectively integrate the use of auxiliaries and eliminate those failed Invisalign cases that have resulted in the erroneous impression that Invisalign is either ineffective or takes longer than traditional braces.

Certain cases, such as surgical orthodontic therapy with skeletal fixation, are most commonly treated with traditional braces.  However, Invisalign is a superior modality for non-surgical, high-angle, and/or anterior open bite cases.  And, for the majority of presentations, as noted above, traditional treatment or Invisalign may be effectively used.

Suitability of Invisalign for a child is highly dependent upon not only the orthodontic diagnosis but also the expected level of patient participation.  The necessity of consistent wear of the clear plastic aligners over the full length of treatment can make Invisalign inappropriate for some individuals, whether adult or child.  (Experience in orthodontic practices across the country indicates that the percentage of patients that present with insufficient aligner wear is similar in adult and teen populations.)  The likelihood of high compliance will be discussed with your orthodontist to determine if your child is a good candidate.  I often ask the younger patient if he or she is the type of person who always makes the bed, or habitually brushes his or her teeth without being reminded.  If the answer is no, accompanied by a chuckle and knowing glance between parent and child, I remind everyone that our ultimate goal is to have an ideal result, which will necessitate 22+ hours of aligner wear every single day of treatment.  If the desire for the benefits of Invisalign is not sufficient to instill the necessary dedication and commitment, I suggest that the family reconsider their options.  Patients that do not sustain the necessary level of aligner wear can still attain an ideal result, but usually only following a transition into braces.  Such cases take longer and may cost more than if they had been started with fixed appliances (braces).  Thus, even though many teens prove to be some of the best Invisalign patients, it is important to have a frank appraisal of the most likely level of patient participation before entering any treatment.

While the vast majority of adult patients seek out Invisalign over braces, some adults opt for traditional treatment, preferring not to remove and replace aligners.  This is particularly appropriate if the patient is both busy and unconcerned with visible brackets.  We offer crystal clear brackets and tooth-colored wires that greatly reduce the visual impact of traditional treatment.  Lingual braces are yet another option for the adult patient.  These options are available in most orthodontic practices and provide the adult with many acceptable alternatives to metal braces.

Regarding treatment length, there are now technologies (Acceledent, Propel, and Wilckodontics) that enhance the biological processes involved in tooth movement, reducing the time required to achieve an excellent orthodontic result by 25-40%, regardless of modality chosen.  Some of these technologies are easily incorporated, such as Acceledent, and can have the added benefit of reducing the discomfort of orthodontic tooth movement.

In all cases, I recommend that you seek an examination with one or more orthodontists and choose that practitioner who is willing and able to address your questions and concerns.  If Invisalign is your preference, you must use your own judgment regarding the practitioner’s expertise.  As an aid, you may wish to inquire about continuing education; Invisalign is a rapidly evolving modality with many opportunities for advanced training.  Some very competent and busy orthodontists have not yet been able to devote time to Invisalign education and, while excellent practitioners of traditional treatment, are not able to effectively and efficiently utilize the Invisalign system.  As Invisalign becomes more and more prevalent this situation will likely become rare.  For the time being, however, potential patients should educate themselves and be willing to ask questions to determine expertise.

Best wishes on your future treatment, and keep smiling!

I bite my tongue: can that be changed?

If you repeatedly bite your tongue or cheek, you may have malocclusion of the dentition that is contributing to this painful situation.  Typically, the shapes of the tooth surfaces facing the tongue (lingual) and cheeks (buccal) are such that, when the teeth are positioned correctly, the tongue and cheeks are guided safely away from the biting area.  If this is not the case, orthodontic treatment may be advisable.  Both children and adults suffer from this problem and can be successfully treated in most cases.  Advancement in orthodontics (e.g., wire technology, Acceledent, TADs, Invisalign, etc . . .) makes such treatment shorter in duration than in years past and appropriate for all ages.  (So talking, or consuming your favorite foods, can once again be enjoyable!)