Dr. David R. Boschken discusses a combination of therapies that can lead to more efficient orthodontic treatment
During my 20-year orthodontic career, it has been my experience that tooth movement can lead to discomfort and pain. It has been reported that orthodontic pain has a prevalence of 72%–100%, perceived as feelings of soreness, pressure, or tension in the affected teeth.1 Even though our mechanics over the past decade have evolved to using more light wires and slow continuous movements, as opposed to steel wires and punctuated movements, patients still complain of discomfort caused by the inflammatory response created when teeth move within bone. In recent years, a majority of my patients have been treated with clear aligner therapy with Invisalign®. Seventy-five percent of my patients, ages 7 years old to 70 years old, are involved in aligner therapy, and within the next 12 to 18 months, that number should rise to 90 percent of patients. With the opportunity to treat these patients more quickly, I felt the necessity to implement a way to make tooth movement less painful as well.
About 6 years ago, I began using the manual osteoperforations (MOPs) technique (Propel), a procedure I use to allow a more targeted planning of tooth movements, as well as speed treatment. MOPs is a process of creating small holes in the bone around the teeth to accelerate tooth movement. I found that this treatment translated to greater efficiency in moving teeth in less time. A few years later, Propel developed an option for orthodontists that patients could use at home — VPro5™, a high-frequency vibration (HFV) aligner seater. In my practice, this device was offered to patients either as an alternative or in addition to MOPs. The device, which was used for 5 minutes each night as per instructions for use was designed to facilitate better aligner seating. When the aligners fit more snugly to the teeth, the result was more efficient tooth movement.
Over time, Invisalign developed a new material — SmartTrack — that improved the process of tooth movement and represented a massive advancement in the technology of plastic and aligner therapy. According to Align Technology, SmartTrack material is a “highly elastic material that delivers gentle, more constant force to improve control of tooth movements.”2,3 The material “conforms more precisely to tooth morphology, attachments, and interproximal spaces, which delivers improved control.”3 VPro5 allowed those aligners to fit even better. Over time, my patients began giving me feedback about a reduction in discomfort and pain in conjunction with VPro5 use. Anecdotally speaking, hundreds of my patients who have used the VPro5 comment that they either feel less discomfort or don’t feel pain when switching aligners every 5 to 7 days.4 I believe that HFV with VPro5 helped us offer that protocol to a greater range of patients with a wide range of clinical issues and compliance levels.
Figures 1 and 2: Patient 1 — Peter. Diagnosis: Class I crowding. Treatment plan: 32 upper and lower aligners, 5-day exchange with HFV each day. Expected treatment time: 12-14 months. Actual treatment time: 5 months
One of my patients, Peter, is an example of how Invisalign and VPro5 can work together. At 26 years and 10 months old, Peter had Class I crowding (Figure 1) that we decided to treat with aligners and HFV. Treatment was expected to take 12-14 months. The treatment entailed 32 upper and lower aligners and HFV each day. Aligners were to be changed every 5 days. At the end of 5 months (Figure 2), no further refinements were needed, and treatment was completed 7 months ahead of schedule.
Another patient, illustrated here, is Ryan. This 36 years and 9 months old patient had Class I crowding and a crossbite (Figure 3), which we had decided to treat with 33 upper and lower aligners to be changed every 5 days and HFV each day. Our expected treatment time was 14.5 months. This compliant patient actually completed treatment in four appointments over the course of 6.5 months (Figure 4). This patient saved approximately four appointment visits and 8 months of treatment time, and needed no refinements.
Figures 3 and 4: Patient 2 — Ryan. Diagnosis: Class I crowding and a crossbite. Treatment plan: 33 upper and lower aligners, 5-day exchange with HFV for each day. Expected treatment time: 14.5 months. Actual treatment time: 6.5 months
Figures 5 and 6: Patient 3 — Hugh. Diagnosis: Class I, spacing issues, and edge-to-edge occlusion. Treatment plan: 17 upper and lower aligners, 5-day exchange with HFV each day. Expected treatment time: 8.5 months. Actual treatment time: 3.5 months
The combination aligner therapy and HFV have continued to provide my patients consistently positive results, even with a range of orthodontic issues. The images speak for themselves. Hugh, 30 years and 10 months old was diagnosed with Class I, spacing issues, and edge-to-edge occlusion (Figure 5). We had expected treatment duration to last 8.5 months, to finish the course of 17 upper and lower aligners and VPro5 each day. After using the aligners and HFV as directed, Hugh actually only needed three appointments and completed treatment in 3.5 months (Figure 6). The patient finished treatment approximately 5 months ahead of schedule with no refinements necessary.
HFV along with MOPs or by itself, in my opinion, helps patients to tolerate the discomfort that goes along with tooth movement. I have treated patients who receive MOPs, switch aligners every 3 days along with the use of VPro5, with high levels of predictability. These patients can complete the course of 24 aligners and be ready for refinements, if needed, in 3-4 months.
We always try our best to ensure that the patients understand HFV technology and how we prescribe it within their orthodontic treatment plan. My Director of Operations, Nicole Pruitt, and I each present accelerated orthodontics at the initial exam. We describe our opinion of the potential clinical benefits of VPro5 as an aligner seater to better capture the clinical movements dialed into each aligner. While time is often shaved off with 5-day aligner changes, we do not emphasize the speed aspect. We want all patients to understand our belief that the VPro5 adds value with a reduction in tracking issues, pain reduction (in our opinion), and better expression of tooth movement. Pruitt adds, “We tell patients that we offer accelerated orthodontics to complement their Invisalign experience. We tell them that the aligner seater (VPro5) will help seat the aligners to give them a better fit, which can give the doctor more predictability in his treatment. The upside is that, if all goes well, it shortens the patient’s treatment time, and we find that it also may help reduce pain in some cases. We find that most of our patients want to be efficient with their treatment, and this gives us another tool to try to make it happen. Happier patients that finish treatment quickly and efficiently create more referrals in our practice.”
After we speak with the patients, about 50% of them accept accelerated orthodontics. Non-accepting patients still track through aligners every 7-10 days for most complicated cases. Accepting patients typically track through aligners at 5 day intervals. Our patients are very compliant, since we see them every 12-14 weeks. Often 25 aligner cases are ready for the refinement stage in less than 5 months with only two appointments.
Health insurer Humana® noted that more than 4 million Americans already wear braces.4 Millions more are looking for an orthodontist to suit their needs. In my practice, in the epicenter of Silicon Valley, new patients not only want a beautiful smile, but also want it “yesterday,” and, of course, they would be even happier if they didn’t experience pain in the process. In 1999, when I started using Invisalign, I could not have attempted to ask patients to switch aligners every 7 days, let alone 5 days. At that time, I was recommending 17 to 18 days. Besides helping patients to achieve beautiful smiles, I also want them to have a positive experience in my office, and offering them an opportunity to move their teeth without discomfort is a major advantage.
Figure 7: VPro5™, a high-frequency vibration aligner seater
- Long H, Wang Y, Jian F, Liao L-N, Yang X, Lai W-L. Current advances in orthodontic pain. Int J Oral Sci. 2016;8(2):67-75.
- invisalign® Science in Every Smile [doctor brochure]. INVISALIGN® INTRODUCES SMARTTRACK. © 2013 Align Technology, Inc. All rights reserved. https://www.invisalign.com.au/doctor/doc/brochures/SmartTrack_brochure.pdf. Accessed August 6, 2017.
- Align Technology Introduces One-Week Aligner Wear for Invisalign® Teen and Full Products [press release]. San Jose, California: Align Technology; October 11, 2016. http://investor.aligntech.com/releasedetail.cfm?ReleaseID =992964. Accessed August 13, 2017.
- Shipley T, Brigham G, Sparaga J. Pain Reduction Observed with Orthodontic Forces and Vibration. [Data on file with manufacturer, Propel Orthodontics, Ossining, New York] 2017.
- Humana. Dental braces: facts and benefits [patient brochure]. https://www.humana.com/learning-center/health-and-wellbeing/healthy-living/dental-braces. Accessed August 13, 2017.
The Excellerator™ series driver has been cleared by the U.S. Food and Drug Administration (FDA) with an indication for manually drilling holes in tissue and bone for orthodontic and dental operative procedures. Propel Orthodontics markets the VPro5™ as a high-frequency vibration aligner seater. This article may describe additional uses of the Excellerator™ series driver or the VPro5™ that have not been evaluated by FDA. Propel Orthodontics provided financial support to the author.