In-house Aligners: Why We Should Fabricate Aligners in Our Clinics?

As digital dentistry is evolving, contemporary orthodontics is embracing clear aligners as a tool more than ever before. On the other hand, aligners are being marketed to patients by aligner companies in every way that is possible. The demand of the end user and the pursuit of the orthodontist toward less chair time has made aligners popular in the last decade. As the price for having all machinery needed to fabricate aligners has decreased, orthodontists may choose to fabricate aligners in-house. In-house fabrication will bring advantages in the price, delivery time, and doctor's time if it is done correctly.

Evaluation of buccolingual molar inclinations among different vertical facial types.

OBJECTIVE: The aim of this study was to compare the buccolingual inclination of maxillary and mandibular molars in adults with different vertical facial types. METHODS: Cone-beam computed tomography images of 135 adult patients (age, 20-45 years) with skeletal Class I maxillomandibular relationships were assigned to normodivergent (n = 46), hypodivergent (n = 49), and hyperdivergent groups (n = 40) according to linear and angular sella-nasion/gonion-menton measurements. The normodivergent group consisted of 24 females and 22 males, hypodivergent group of 26 females and 23 males, and hyperdivergent group of 24 females and 16 males. Buccolingual inclination of the maxillary and mandibular first and second molars was measured relative to the occlusal plane. One-way analysis of variance was used for intergroup comparison. Gender differences were evaluated using independent t-tests. RESULTS: Buccolingual molar inclinations did not differ significantly between females and males (p > 0.05). There were no statistically significant differences among the buccolingual inclinations of the first and second maxillary and mandibular molars of the groups (p > 0.05). CONCLUSIONS: Buccolingual inclinations of maxillary and mandibular molars are similar in normodivergent, hyperdivergent, and hypodivergent adults with Class I sagittal relationships.

Comparison of Different Energy Levels of Er:YAG Laser Regarding Intrapulpal Temperature Change During Safe Ceramic Bracket Removal.

OBJECTIVE: This study was done to compare the intrapulpal temperature change generated by different energy levels of Er:YAG laser used during debonding of ceramic brackets and find the most suitable level for clinical use. MATERIAL AND METHODS: Eighty polycrystalline alumina brackets were bonded on bovine incisor teeth, which were randomly divided into 4 groups of 20. One group was assigned as control. In the study groups, after laser exposure with 2, 4, or 6 Watt energy levels, brackets were debonded using an Instron Universal Testing machine. Adhesive remnant index (ARI) scores were recorded to evaluate the site of debonding. To assess intrapulpal thermal increase, 60 human premolar teeth that were prepared in the same way, at the same energy levels, by a thermocouple were used. RESULTS: When the debonding forces, intrapulpal temperature increases, and ARI of the groups were examined, statistically significant difference was observed between the groups. Mean temperature increases of 0.67°C ± 0.12°C, 1.25°C ± 0.16°C, and 2.36°C ± 0.23°C were recorded for the 2, 4, and 6 Watt laser groups. The mean shear bond strength was 21.35 ± 3.43 megapascals (MPa) for the control group, whereas they were 8.79 ± 2.47, 3.28 ± 0.73, and 2.46 ± 0.54 MPa for the 2, 4, and 6 Watt laser groups, respectively. CONCLUSIONS: Four watts is the most efficient and safe energy level to be used, utilizing Er:YAG laser with water cooling spray for 6 sec by scanning method during debonding of polycrystalline alumina brackets without any carbonization effects and detrimental temperature changes at debond sites.

Treatment of a Class II Case with Palatally Inserted Distalization Mechanics in an Epilepsy Patient.

This case report describes the protocol employed in the treatment of a patient with Class II malocclusion with mechanics including palatally positioned miniscrews. Treatment included the distalization of maxillary posterior teeth with mechanics including 2 miniscrews positioned on the palatal side. After a certain amount of distalization was achieved, the maxillary arch was bonded with Roth prescription brackets while the appliance was still active. When leveling of the upper arch was finished, the appliance was kept in the mouth as a retention device while the mandibular arch was bonded to continue treatment, which lasted for a total of 15.5 months. Mandibular and maxillary fixed retainers were placed at the end of active treatment. Pretreatment and post-treatment records revealed that vertical and sagittal skeletal cephalometric findings were not affected. Miniscrew anchorage used during distalization is an effective non-extraction treatment option for dental Class II malocclusion correction.

Periodontal, dentoalveolar, and skeletal effects of tooth-borne and tooth-bone-borne expansion appliances.

INTRODUCTION: The purposes of this study were to evaluate and compare the periodontal, dentoalveolar, and skeletal effects of tooth-borne and tooth-bone-borne expansion devices using cone-beam computed tomography. METHODS: Twenty-five patients requiring maxillary expansion were randomly allocated into 2 groups. A tooth-borne hyrax appliance was used in the first group, consisting of 13 patients (8 girls, 5 boys; mean age, 14.3 ± 2.3 years), and a tooth-bone-borne hybrid hyrax appliance was used in the second group of 12 patients (6 girls, 6 boys; mean age, 13.8 ± 2.2 years). Cone-beam computed tomography records were taken before and 3 months after expansion, and periodontal, dentoalveolar, and skeletal measurements were made on the cone-beam computed tomography images with a software program. The 2 independent-samples t test and the Mann-Whitney U test were used to evaluate treatment changes for both groups. Paired-samples t test and Wilcoxon test were used to compare the measurements at 2 time points for variables. RESULTS: Significant skeletal changes and increases in interdental distances were observed in both groups. However, the distances between the first and second premolars increased more with the hyrax appliance (7.5 ± 4.2 and 7.9 ± 3.3 mm, respectively) than with the hybrid hyrax (3.2 ± 2.6 and 4.5 ± 3.8 mm, respectively) (P <0.05). Similar reductions in buccal bone plate thickness and increases in palatal bone plate thickness of the anchored teeth occurred in both groups, whereas changes in buccal and palatal bone thicknesses of the left first premolars significantly differed between groups (P <0.001). No significant intergroup difference was found in terms of absolute dental tipping. CONCLUSIONS: Both tooth-borne and tooth-bone-borne rapid expansion are effective methods for treating a narrow maxilla. However, the hyrax appliance resulted in greater expansion in the premolar region. On the other hand, the hybrid hyrax appliance did not cause changes in the bony support of the first premolars.

Maxillary buccal cortical plate inclination at mini-screw insertion sites.

OBJECTIVE: To evaluate whether buccal cortical bone inclination varies for the maxillary alveolar processes of adult patients with decreased, normal, and increased facial heights. MATERIALS AND METHODS: Cone-beam computed tomography images of 135 adult patients, including 49 hypodivergent subjects (26 women, 23 men), 40 hyperdivergent subjects (24 women, 16 men), and 46 normodivergent (25 women, 21 men) were analyzed. Cortical bone inclination measurements were made relative to the occlusal plane. Cross-sectional slices of the maxilla were taken at interdental sites from the distal aspect of maxillary canine to the mesial aspect of maxillary second molar. RESULTS: Analysis of variance indicated significant differences (P < .05) between the angles formed by the line tangent to the cortical bone and the occlusal plane among the vertical facial types for the regions between canine and first premolar and between second premolar and first molar at miniscrew insertion sites. CONCLUSION: The results of this study indicate that vertical facial pattern should be taken into consideration when adjusting the insertion angle of miniscrews at the maxillary buccal region.

A report on the use of Er:YAG laser for pilot hole drilling prior to miniscrew insertion.

The aim of the present in vitro study was to investigate the required time period of the Er:YAG laser that is used for drilling through cortical bone when pilot hole drilling is needed before miniscrew insertion. Even though Er:YAG laser is used in various in vivo and in vitro studies, there is no accepted procedure of laser for depth control during drilling through cortical bone. The study sample consisted of 120 cortical bone segments having 1.5 and 2.0 mm of cortical bone thickness. An Er:YAG laser, with a spot size of 1.3 mm and an air-water spray of 40-50 ml/min, was used. The laser was held 2 mm away from and perpendicular to the bone surface with different laser settings. Twelve specimens were prepared for each subgroup. As the cortical bone thickness increased, the time needed to drill through the bone increased. Frequency increase directly caused a decrease in irradiation duration. When three different frequency, three different energy, and four different power values were tested for both the 1.5- and 2-mm cortical bone thicknesses, the shortest duration needed to drill through cortical bone was seen in the 3.6-W (300 mJ-12 Hz) setting. When pilot holes are drilled prior to miniscrew placement in 1.5 to 2 mm of cortical bone using Er:YAG laser, the most appropriate value is found with the 3.6-W (300 mJ-12 Hz) setting.

Pulpal thermal changes following Er-YAG laser debonding of ceramic brackets.

Lasers are effective in debonding ceramic brackets. Unfortunately, while reducing the adhesive bond strength, lasers are also reported to increase pulpal temperature. The aim of this study was to evaluate the shear bond strengths and temperature increase levels after debonding ceramic brackets using an Er-YAG laser with or without water-cooling. Sixty polycrystalline upper premolar ceramic brackets were placed on the labial surface of sixty human premolar teeth which were randomly divided into three groups of twenty. A laser pulse at 5 W for 9 seconds was delivered to each bracket in both study groups either with water-cooling (water group) or without water-cooling (waterless group) using an Er-YAG laser. Debonding was performed 45 seconds after laser exposure and shear bond strengths were measured. Data comparison revealed a statistically significant difference between the groups. Mean temperature increases of 2.41°C and 4.59°C were recorded for the water and waterless laser groups, respectively. The shear bond strength value for the control group was 22.76 MPa and 10.46 and 6.36 MPa for the water and waterless laser groups, respectively. The application of Er-YAG laser with water-cooling was an efficient and safe method of debonding ceramic brackets.

Cortical bone thickness of the adult alveolar process--a retrospective CBCT study.

OBJECTIVES: To investigate and compare cortical bone thickness of the posterior alveolar process in adult patients presenting with skeletal Class I, II and III malocclusions. METHODS: Cone beam computed tomographic (CBCT) images of 196 adult subjects, aged 20-45, were evaluated. Cortical bone thickness was measured 4 mm from the alveolar crest, as the shortest bucco-lingual dimension of the cortical bone at interdental sites from the distal of the maxillary canine to the mesial of the maxillary second molar. RESULTS: There were no differences between the malocclusion groups in mean age, gender, or vertical pattern (p > 0.05). At all sites measured, there were no statistically significant differences in the means of cortical bone thickness between the groups (p > 0.05). Maxillary palatal bone thickness was reduced in the Class I (p < 0.0001), and Class II (p < 0.001) groups; but mandibular buccal thickness increased significantly (p < 0.001) in all malocclusion groups from anterior to posterior. CONCLUSIONS: There was no difference in cortical bone plate thickness between Class I, II and III subjects when related to mini-implant placement sites. As the measurement site moved towards the posterior, maxillary palatal cortical thickness decreased except in Class III cases, while mandibular buccal bone thickness increased in all malocclusion groups.

Quantitative evaluation of alveolar cortical bone density in adults with different vertical facial types using cone-beam computed tomography.

OBJECTIVE: The purpose of this study was to quantitatively evaluate the cortical bone densities of the maxillary and mandibular alveolar processes in adults with different vertical facial types using cone-beam computed tomography (CBCT) images. METHODS: CBCT images (n = 142) of adult patients (20-45 years) were classified into hypodivergent, normodivergent, and hyperdivergent groups on the basis of linear and angular S-N/Go-Me measurements. The cortical bone densities (in Hounsfield units) at maxillary and mandibular interdental sites from the distal aspect of the canine to the mesial aspect of the second molar were measured on the images. RESULTS: On the maxillary buccal side, female subjects in the hyperdivergent group showed significantly decreased bone density, while in the posterior region, male subjects in the hyperdivergent group displayed significantly decreased bone density when compared with corresponding subjects in the other groups (p<0.001). Furthermore, the subjects in the hyperdivergent group had significantly lower bone densities on the mandibular buccal side than hypodivergent subjects. The maxillary palatal bone density did not differ significantly among groups, but female subjects showed significantly denser palatal cortical bone. No significant difference in bone density was found between the palatal and buccal sides in the maxillary premolar region. Overall, the palatal cortical bone was denser anteriorly and buccal cortical bone was denser posteriorly. CONCLUSION: Adults with the hyperdivergent facial type tend to have less-dense buccal cortical bone in the maxillary and mandibular alveolar processes. Clinicians should be aware of the variability of cortical bone densities at mini-implant placement sites.

Cortical bone thickness of the alveolar process measured with cone-beam computed tomography in patients with different facial types.

INTRODUCTION: The purpose of this study was to determine the cortical bone thickness of the alveolar process in the maxilla and the mandible on cone-beam computed tomographs of adults with low, normal, and increased facial heights. METHODS: This study was conducted on 155 images of adult patients (20-45 years old) who were assigned to the low-angle, normal, and high-angle groups. The thickness of the buccal cortical plates of the maxilla and the mandible, and the palatal cortical plates of the maxilla, were measured. RESULTS: There was no statistically significant difference between the groups regarding mean ages, sex, and sagittal facial types. High-angle patients had significantly lower values than did low-angle patients in all mini-implant insertion sites in both the maxillary and mandibular alveolar bones. The mandibular and maxillary buccal measurements showed a similar pattern; the lowest values were for the high-angle group, followed by the normal group; the highest values were measured in the low-angle patients. CONCLUSIONS: Clinicians should be aware of the probability of thin cortical bone plates and the risk of mini-implant failures at maxillary buccal alveolar mini-implant sites in high-angle patients, and at mandibular buccal alveolar mini-implant sites between the canine and the first premolar in normal and high-angle patients.

Effects of a newly designed apparatus on orthodontic skeletal anchorage.

OBJECTIVE: An appliance was designed to increase the cortical bone surface contact area of miniscrew implants (MSIs). The purpose of this in vitro study was to evaluate the effects of this appliance on the anchorage force resistance and the stability of orthodontic MSIs. MATERIALS AND METHODS: A total of 48 MSIs were placed into bone specimens prepared from the ilium of bovines. Half were placed with the newly designed apparatus and half were placed conventionally. All the specimens were subjected to tangential force loading perpendicular to the MSI with lateral displacement of 0.6 mm, using an Instron Universal Testing machine. The maximum removal torque of each tested specimen was also recorded. Both study and control groups were divided into two subgroups based on whether they had thin and thick cortical bone. RESULTS: The test group had statistically higher force anchorage resistance and maximum insertion torque values than the control group (P < 0.001). The results were found to be more significant in cases in which the cortical bone was thin (P < 0.001). CONCLUSIONS: Within the limits of this in vitro study, the present findings suggest that the newly designed apparatus might have a favorable effect on MSI stability in patients presenting with thin cortical bone. Clinical studies are necessary to confirm the results that were observed in vitro.

FEM analysis of a new miniplate: stress distribution on the plate, screws and the bone.

OBJECTIVES: Non-homogeneous force distribution along the miniplates and the screws is an unsolved question for skeletal anchorage in orthodontics. To overcome this issue, a miniplate structure was designed featuring spikes placed on the surface facing the cortical bone. The aim of this study was to examine and compare the force distribution of the newly designed plate-screw systems with the conventional one. METHODS: A model of bone surface with 1.5 mm cortical thickness, along with the two newly designed miniplates and a standard miniplate-screw were simulated on the three-dimensional model. 200 g experimental force was applied to the tip of the miniplates and the consequential effects on the screws and cortical bone was evaluated using three-dimensional finite element method. RESULTS: As a result of this finite element study, remarkably lower stresses were observed on the screws and the cortical bone around the screws with the newly designed miniplate when compared with the conventional one. CONCLUSION: The newly designed miniplate that has spikes was found effective in reducing the stress on and around the screws and the force was distributed more equivalently.

Effects of different application durations of scanning laser method on debonding strength of laminate veneers.

Porcelain laminate veneers as esthetic and minimally invasive restorations are being used as an alternative to full veneer crowns. However, the removal of porcelain veneers that have failed may be an uncomfortable and time-consuming procedure because of the high bond strength between the porcelain laminate veneers and the tooth surface. The purpose of this study was to prepare a simple and reliable method for porcelain laminate veneer debonding by using an Er:YAG laser with the scanning method and to determine the amount of lasing time required. Eighty cylindrical specimens with a thickness of 0.7 mm and a diameter of 5 mm were fabricated from Empress II ceramic material. They were cemented on the labial surface of extracted bovine mandibular incisors using Variolink II (Ivoclar Vivadent AG, Schaan, Liechtenstein) and light cured for 40 s. The specimens were randomly divided into four groups of 20. The first group was assigned as the control group and no laser application was performed. The Er:YAG laser was applied on each specimen in the other three study groups for 3, 6, and 9 s by using the scanning method. One second after the lasing, a mechanical force was applied to remove the laminate veneers by using an Instron Universal Testing machine. Results of this study exhibited statistically significant differences between the control group and the three study groups. Intergroup comparison of shear bond strengths of the three study groups showed a statistically significant difference (p = 0.0001). This study showed that all three application times of Er-YAG laser were effective for debonding ceramic laminate veneers by softening the adhesive resin.

Comparison of shear bond strengths of ceramic brackets after different time lags between lasing and debonding.

Laser use is effective in the debonding of ceramic brackets. However, a standardization of the laser debonding techniques used has not yet been implemented. The purpose of this study was to evaluate the effect of the time lag elapsed between lasing and shearing on debonding of ceramic brackets. One hundred polycrystalline ceramic brackets were placed on human premolar teeth, which were randomly divided into five groups of 20. One group was assigned as the control. The Er-YAG laser was applied on each bracket in four experimental groups at 5 W for 6 s with the scanning method. Debonding was performed 1 s, 18 s, 30 s, or 60 s after laser exposure. Shear bond strengths and adhesive remnant index scores were measured. Statistically significant difference was observed between the control and experimental groups when the data for the shear bond strengths was considered (p < 0.05). Adhesive remnant index scores of the groups were not statistically different (p > 0.05). Debonding ceramic brackets after 18 s when lased 6 s using an Er-YAG laser with the scanning method is safe and also suitable for clinical use since three brackets can be debonded at a time in succession.

Effects of different application durations of ER:YAG laser on intrapulpal temperature change during debonding.

This study was done to determine the amount of lasing time required to remove ceramic brackets safely without causing intrapulpal damage by using Er:YAG laser with the scanning method. Part 1: 80 bovine mandibular incisors with ceramic brackets were randomly assigned into four groups of 20 as one control and three study groups. In the study groups, brackets were debonded after lasing for 3, 6, and 9 s, whereas debonding was performed without lasing in the control group. Shear bond strengths and ARI scores were also measured. Part 2: 30 human premolars with ceramic brackets were randomly divided into three groups of ten, as 3, 6, and 9 s of lasing durations. Intrapulpal temperature was measured at the same lasing times by a thermocouple. Statistically significant lower shear bond strengths were found in study groups compared to the control. A negative correlation was seen between the bond strengths and ARI scores in such a way that, as the shear bond strengths decreased, the ARI scores increased. Temperature increases for all the study groups were measured below the 5.5°C benchmark. All lasing times were effective for debonding without causing enamel tear outs or bracket failures. The temperature proportionally increased with the extension of the lasing duration. Six-second lasing by the scanning method using Er:YAG laser was found to be the most effective and safest way of removing the ceramic brackets without causing damage to the enamel and pulpal tissues.

Debonding of ceramic brackets by a new scanning laser method.

INTRODUCTION: The purpose of this in-vitro study was to develop a new method to debond ceramic brackets by scanning with an Er:YAG laser. METHODS: Sixty bovine mandibular incisors were randomly divided into 2 groups of 30. Polycrystalline ceramic brackets were placed on their labial surfaces by using the orthodontic composite adhesive Transbond XT (3M Unitek, Monrovia, Calif) and light cured for a total of 40 seconds. The first group was the control group, with no laser application performed. The Er:YAG laser was used on each bracket in the study group at 4.2 W for 9 seconds with the scanning method. The force required for debonding the brackets was applied 45 seconds after laser exposure. Shear bond strengths were measured in megapascals with a universal testing machine, and adhesive remnant index scores were assigned to each specimen. RESULTS: Statistically significant (P <0.001) lower shear bond strengths were found in the laser group (9.52 MPa) compared with the control group (20.75 MPa). Likewise, the adhesive remnant index scores were statistically different (P <0.001); the laser group had twice as many samples with adhesive, with the adhesive remnant index scores of 2 or 3. CONCLUSIONS: The application of the Er:YAG laser with the scanning method is effective for debonding ceramic brackets by degrading the adhesive through thermal softening.