Dr. Gary Brigham discusses his experience with an efficient, productive, and patient-friendly device
You miss 100% of the shots you don’t take.
— Wayne Gretzky
Over the past 2 years, I have had the opportunity to progressively incorporate micro-osteoperforations (MOPs) using the Propel® System into my practice. During the course of this integration, I have used both the initial Excellerator and the second-generation Excellerator RT (replaceable tip) (Figure1) with a significant degree of success both in clinical efficiency and outcome. With the introduction of Propel’s new power driver, the Excellerator PT (power tip) (Figure 2), my capacity to conduct MOPs has been elevated to a remarkably new level of clinical experience.
As previously described,1 I was initially reluctant to even consider adopting this treatment modality. While acknowledging and respecting the science supporting MOPs,2-4 I nevertheless considered the procedure invasive and obtrusive and assumed that my patients would mirror my concerns. I could not have been more mistaken.
While I continued to follow the clinical success and impressive clinical outcomes of early adopters of MOPs,5-8 I was simultaneously confronted with an increasing demand from my own patients to meet their esthetic and functional needs with less time in treatment. Accordingly, I set aside my questions and embraced the modality, starting with the Excellerator and graduating to the Excellerator RT, which increased efficiency and patient comfort. As with the aforementioned early adopters, I began to immediately witness both successful clinical outcomes and remarkably increased patient satisfaction with the integration of MOPs.
An Excellerator that accelerates MOPs
Several months ago, I was afforded the opportunity to try Propel’s new power driver, the Excellerator PT. Until then, I had been pleased with my progress with the technique and use of the Excellerator RT. For example, I learned that it is ergonomically more efficient and effective to stand chairside when using the hand driver. However, I still recognized the benefits of integrating the new power driver into the MOPs protocol immediately.
First, the power driver is fast, fluid, and with its push button delivery both in forward and reverse modes, is exceptionally easy to control while completing the MOP’s application in less time than with the Excellerator RT. The power driver offered by Propel for use with the PT tips operates at higher RPMs than most battery-operated torque drivers currently available. The higher operating speed and adjustable torque settings are optimal for the micro-osteoperforation procedure. A standard torque driver would be slow and inefficient when making multiple perforations. So the power driver offered by Propel provides the right combination of control and efficiency.
Second, the increased patient comfort with the entire procedure was immediately evident. For example, in using the hand-driven accelerators, I found that it was occasionally necessary to supplement the topical anesthetic gel BTT (lidocaine 12.5%, tetracaine 12.5%, prilocaine 3%, phenylephrine 3%, Woodland Hills Pharmacy, Woodland Hills, California) with local infiltration anesthesia using Septocaine® (articaine HCL 4% and epinephrine 1:100,000). I attribute this to my exacting some degree of torque to the interdental bone when performing MOPs with the hand/wrist delivery application of the Excellerator RT. It has been speculated that incorporating operator-induced torque to the alveolar bone creates micro-stresses. These micro-stresses radiate from the perforations to the nerve endings of the periodontal ligaments of adjacent teeth and are likely responsible for the sensitivity. Since using the Excellerator PT, it has not been necessary to use any supplemental local infiltration anesthesia. Moreover, for patients who underwent an initial Propel procedure using the Excellerator RT and then underwent a second procedure using the Excellerator PT, the response was unanimously in favor of the Excellerator PT as the driver that produced the greatest level of patient comfort.
Third, by virtue of the contra-angle latch type driver holder assembly of the Excellerator PT (Figure 3), access to previously difficult areas, such as the molar regions, is no longer challenging. This is particularly beneficial where MOPs, applied to the maxillary buccal segments in high angle/anterior open bite cases, is critical to facilitating the intrusion of these posterior teeth. Finally, ensuring sterile technique is effortless. The single-use contra-angle perforation screws are individually packaged and sterilized with gamma radiation, and the contra-angle driver holder easily detaches from the motorized hand piece for autoclaving.
Propel, Invisalign®, and smile-driven orthodontics
Any clinician with significant experience with clear plastic aligners will likely agree that, the more cases that are completed using Invisalign, the more complicated the treatment of new cases (as well as their ClinCheck®) becomes. The reason for this phenomenon is that, with increased skill in the use of Invisalign, most clinicians will necessarily expand his/her treatment goals. Whereas alignment of malposed teeth was once the principal goal (and sometimes the only objective) of treatment, the experienced clinician often strives to create ideal occlusions that require the least amount of neuromuscular adaptation to function, as well as esthetic smile arcs with idealized tooth axial inclinations. Along with the increase in detail delivered by ClinCheck® Pro, there has been a natural increase in the number of attachments to effect these additional changes. Clinicians have to only review the excellent clinical outcomes display in the education section of Invisalign’s doctor website to appreciate the evolution in both treatment objectives and results that have occurred over the past decade.
However, this expansion in treatment objectives has created a clinical conundrum for many clinicians. For example, where a patient was once regarded as a case that could readily be treated with Invisalign Express (maximum of 10 aligners), the nature of the case changes significantly when incorporation of a smile arc to maximize smile-driven esthetics is considered. The application of the Nicozisis Extrusion Protocol9 to extrude the maxillary incisors necessarily adds a considerable number of aligners to achieve the desired results, specifically because purely vertical extrusive movements using Invisalign are not practical. Although patients expect impressive clinical results, they are normally not willing to accept the additional treatment time required to realize those results.
Incorporating the use of Propel addresses this problem directly. Following the procedure, when patients are directed to exchange their aligners every 3, 5, or 7 days according to aligner tracking, the number of aligners required to complete treatment becomes inconsequential.
Case No. 1 illustrates this point. The patient had previously been treated with fixed appliances. However, the arches had since constricted, and the mandibular incisors had collapsed labially. The proclined incisors resulted in heavy palatal contacts to the maxillary central incisors that resulted in their anterior displacement with spacing that created an esthetic concern for the patient. In addition, the distal aspects of the maxillary lateral incisors had rotated palatally, reinforcing the illusion of a “two-tooth smile” when viewed frontally. Finally, an unesthetic reverse smile arc was evident.
The patient expressed a desire for a broader and more esthetic smile with straight teeth. A total of 24 aligners were required to achieve the treatment objectives, which under traditional aligner exchanges of every 2 weeks, would result in 12 months of treatment. However, 2 months after the aligners were delivered, all attachments were placed, and interproximal reduction (IPR) was completed, the patient underwent Propel to both arches and initiated the 3/5/7 day exchange protocol. Treatment was completed in 5 months and 2 weeks.
Case No. 2 presented with a Class I malocclusion characterized by an excessive 60%-70% overbite, 3 mm overjet, an occlusal cant to the patient’s left, a maxillary midline discrepancy to the patient’s right of 2 mm, a right Class II canine relationship, and a significant Bolton discrepancy in the maxillary arch. Both arches were constricted, with procumbent and crowded mandibular incisors. The patient expressed concern for the midline discrepancy, the overbite, and the unesthetic appearance of her smile.
A total of 41 aligners were required to achieve the treatment objectives, which under the 2-week aligner exchange format, would result in almost 21 months of treatment. The patient initially rejected Propel as a treatment option at the treatment plan presentation. However, after 8 months of treatment at an aligner exchange of every 2 weeks (total of 16 aligners), the patient requested a review of the Propel procedure and subsequently accepted treatment. Accordingly, Propel was initiated, and the patient was placed on the 3/5/7 day aligner exchange protocol. Treatment was completed in 10 months and 3 weeks.
Case No. 3 presented with a Class I malocclusion characterized by 20% overbite, 2 mm overjet, severe bimaxillary arch constriction/ collapse, severe mandibular anterior tooth crowding, the absence of four first bicuspids from previous fixed appliance treatment, and a paucity of free gingiva labial to the mandibular anteriors. The patient’s principal concern was the unesthetic appearance of her smile. The treatment ClinCheck® required a total of 34 aligners. Propel was initiated at the beginning of treatment, and the patient was placed on the 3/5/7 day aligner exchange protocol. Treatment was completed in 6 months.
Epilogue
Micro-osteoperforation has already proven to stimulate a cytokine cascade response in interdental bone that results in an increase in the rate of orthodontic tooth movement. Propel has been a leader in delivering patented medical devices that truncate orthodontic treatment time regardless of the type of appliance used. Incorporating the use of Propel into our practice has resulted in consistently improved treatment efficiency, productivity, and remarkable patient satisfaction without compromising clinical outcomes.
After using all three Propel devices, I much prefer the Excellerator PT. Having witnessed the reaction of patients who have experienced both the Excellerator PT and one of the other hand-driven devices, I am convinced that the powered device is more efficient, productive, and patient friendly. I would at least encourage clinicians to evaluate it for their own Propel procedures.
This information is sponsored and provided by Propel Orthodontics.
Gary Brigham, DDS, MSD, earned his doctorate at Case Western Reserve University, where he also received his certificate in orthodontics and a master’s degree in Immunology. He was awarded the Harry Sicher Award from the AAO for his graduate research and served as an Assistant Professor of Pediatric Medicine at the Center for Craniofacial Anomalies at the University of Illinois at the Medical Center in Chicago. He has lectured throughout the United States for Align Technology since 2004 and is the recipient of Align’s first award for service to the orthodontic profession. Dr. Brigham currently serves as an Adjunct Professor of Orthodontics in the orthodontic graduate program at the A.T. Still School of Dentistry and Oral Health, where he is the dedicated Invisalign® instructor. He maintains a full-time practice in Scottsdale, Arizona.
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