Technology Update: Digital Orthodontics

Elsewhere under "Technology Updates", The Suresmile tm system is explained. In a similar vein, the December 2009 issue of The American Journal of Orthodontics features an interview with Dr. David Sarver regarding his use of the Insignia tm system by Ormco of Orange, CA. since 1997. Like Suresmile tm, Insignia tm provides customized brackets and wires instead of standardized materials. He is an author of several orthodontic textbooks, an adjunct professor in Orthodontics at the University of North Carolina, Chapel Hill and in private practice in Alabama. The interviewer, Dr. Robert Scholz, also a colleague of Dr. Sarver at UNC, states that to date, he has " seen no data proving " that Insignia tm " greatly reduces treatment time." Increased efficiency and speed of treatment are sometimes cited as being among the benefits of both techniques. Dr. Sarver " lament(s) the recent emphasis on speed of treatment over quality" and while he has data in his office that does " reflect less average treatment time", he has " not really analyzed it statistically" and is therefore " reluctant to say that treatment time has been reduced". Dr. Sarver is selective in which case types are recommended for Insignia tm therapy, acknowledges its higher cost and is generally supportive of its use as a marketing tool directed towards dentists and patients desiring an individualized rather than a " one size fits all" approach.

A randomized controlled study certainly could and should have been done in the past 13 years comparing Insignia tm and conventional therapy in similar case types by someone. When and if this occurs, even if either technique proves to be faster and/ or better than conventional therapy, the issue of retention after the braces are removed remains. Relapsed teeth don't care how fast they were straightened or by which technique. This rationalizes our use of bonded lingual wires behind the upper and lower front six teeth for years after removal of the braces. See our long term results in the Gallery.

Why does this matter? In the current debate over high healthcare costs, a primary cost driver is new technology...not necessarily better technology. This distinction has been well studied, for example, with a robot assisted procedure for prostectomy and the conventional surgical procedure. Studies seem to conclude that in the hands of experienced surgeons, both procedures produce similar results but the former technique is considerably more costly. Since Medicare is the primary payor in these patients, we all end up assuming the higher cost without a better validated outcome in the 85% of patients who now demand the robotic technique and its costing us many millions of dollars more than necessary.

With reference to orthodontic techniques, I feel that new technology should be held to a comparative standard of proven outcomes and be shown to be superior and cost effective before widespread adoption. Trying new things is great...we do it with materials all the time in an incremental way. Changing entire techniques is a different proposition requiring, in my view, a much higher standard of proof beyond industry or media driven hoopla.

 

Temporary Anchorage Devices (TAD'S)
While most people have heard that dental implants can be used to permanently replace missing teeth, another emerging and related class of implants known as TAD'S have made their way into orthodontic technology. These devices are essentially lag screws, which can be placed in suitable bone almost anywhere in the jaws on a temporary basis for the purpose of providing a stable point (anchorage) against which teeth can be moved in a particular direction during orthodontic treatment. For maximum patient comfort and safety, we have oral surgeons place the TAD'S under local anesthesia in the location(s) we specify. Long-term research is not yet available for these devices but short term clinical studies are promising. The theory behind their use is well founded and the downside risks are minimal. With proper use, TAD'S are likely to revolutionize orthodontic care in several ways. For example, it's possible that in some cases where jaw surgery would have been the treatment of choice, TAD'S would allow a similar result without the surgery. Currently, our TAD usage is primarily directed towards achieving headgear or Forsus Appliance type movement without patient compliance. Watch our website in future months for examples of what we have been able to achieve with TAD'S.
 

 

Self - Ligating Braces

There are many differently engineered systems of braces which possess varying characteristics with respect to appearance, material from which they are made, ease of use and cost. It is fair to say that there is almost always more than one way to treat a case and more than one type of appliance with which to treat it. A self-ligating brace or bracket has an internal mechanism to engage the archwire rather than using an elastic type circular "o" to stretch over the "wings" of conventional braces. They are not new, as we used them 25 years ago, but are experiencing a recent renaissance with claims of being able to achieve faster results with fewer monthly adjustments. We will consider using self-ligating braces in selected cases where their use will benefit the patient to a greater degree than conventional braces.

 

Suresmile™
Having attended their seminar presentation, here are my impressions of this potentially game changing technology: -Using digital recreations of the teeth with the braces placed and transmitting it over the Internet to their lab, robots shape the wires to be placed in the braces in such a way as to achieve the doctors prescription for the position of each tooth. This methodology is said to produce extremely accurate results, expedite and thereby shorten the duration of treatment and potentially decrease discomfort and root resorption sometimes associated with conventional braces. Only internal company data is available to date analyzing patient outcomes which purport to support these claims. We heard two practitioners with a great deal of clinical experience support these claims. It is important to note that to the best of my knowledge, controlled studies in an academic environment have not been published to support their claims. Further, the data has not been segregated by case type and therefore on an individual basis, may not be predictive of the outcome with reference to the claims made about this technique.

Some potential issues we will consider before adopting this technique:

1. Cost is significantly higher then conventional braces in the range of $800-$1000 per case
2. A 5-7 day delay between scanning the teeth and braces for the wire prescription and taking delivery of the wire to be placed in the patients mouth.
3. Certain case types will undoubtedly treat out more quickly with this technique but others may not. As with any new technology, universal application may not be appropriate or necessary. Also, the advanced wire alloys used are already available to us with conventional braces and have many useful properties, which can expedite conventional treatments as well. Whether outcomes between these techniques using these wires are significantly different remains to be seen.
4. Technological progress is almost always incremental where as this technique is in part promoted as the future of Orthodontics. That’s a big claim…. we’ll see.
5. The company, Orametrix, had revenue last year of about $10 million with a combined total of research, development and sales costs since it’s founding approaching $120 million. Whether or not this company remains viable will ultimately be determined by profitability in the marketplace. They seem very confident of success. Again, time will tell.
6. Their technology is impressive, as is their marketing effort. If and when we become an adopter, we would consider its use on a case by case basis.
7. In our world where so many of our adult cases are retreatments, meaning that a previous orthodontic treatment proved to be unstable, the “ holy grail” as we see it is to achieve long term retention rather than being preoccupied with how fast the treatment progressed which this technology purports to address. A widely accepted viewpoint in orthodontics is that the faster the teeth are moved and the less time they’re held in position, the greater the chance of root damage and/or post treatment instability. To date, I am unaware of a published retention study involving Suresmile tm probably because they haven’t been in use long enough. In our practice, we routinely demonstrate in 10-20 year posttreatment follow-ups the stability of our cases over these time frames using bonded retainers individually attached to the back sides of the upper and lower six front teeth. See our website for examples of our work. In the final analysis, our patients value long term stability and are generally not focused on saving a few months in treatment. It may be possible however to achieve both and we remain open to that if it makes sense.
8. Technology as an end in itself is problematic in an age of rapidly escalating health costs. Manufacturers intend to profit in the push to integrate advanced technologies which sometimes precede a demonstrated need which may or may not be of meaningful benefit to the patient. And even if there is some benefit, a cost/benefit analysis is lost among the hype for the new technology. We probably can’t afford to keep adopting technology in this way.