Patients gain early rotation correction and improved torque control

Dr. Michael Bicknell discusses how harnessing advancements in technology can satisfy core values and lead to improved patient experiences, simplification of treatment, and improved clinical outcomes

Introduction

“Perception is reality” is a phrase that floats around in all areas of life. In today’s society, this holds even more weight due to the easy access to information, obsession with social media, and all-things advertising. When I think of a phrase like this and try to understand how it can help me to best understand my patients, I formulate questions. How do we present ourselves to our prospective patient base? How do our teams view us as both practitioners and leaders? How do our colleagues and peers evaluate our commitment to excellence and the progression of our profession? These questions and many others are quickly answered by the core values held by an organization’s leadership. Core values drive our decision-making process in all areas of life and are the most important attribute we can express to create trust in serving our patients.

Additionally, core values set and enforce our teams’ culture that creates the environment in which we provide care. If the leadership’s core values are clear and the decisions made support these values, many things happen:

• Patients feel the message presented is the one delivered.
• The teams become harmonious and loyal to the mission of the practice.
• Emotional conflict is reduced because everyone is operating in an environment within the parameter of their value sets.

When all these occur, perception does become a reality.

The reason for the discussion of core values is that it prefaces how and why we make decisions for the services we provide as orthodontists. In my practice, three core values are held and must be satisfied with each decision made:

1. We will always work to improve the patient experience.
2. We must progress our profession by using advancements in technology.
3. We must simplify treatment while improving our outcomes.

Suppose we can find ways to improve the patient experience by using technology and, at the same time, simplify the treatment process and improve outcomes. In that case, we will create improved office cultures, less stressful workplaces, and an overall better environment to treat patients and provide world-leading care.

One of the choices in today’s marketplace that seems to satisfy these core values is the newly designed Damon Ultima™ System by Ormco™ Corporation, which is an advanced bracket-wire system that has been in the making for many years. It is not only a modification of a current bracket design, but also an entirely new product engineered from the ground up to help solve the current problems associated with the inefficiency inherent in all products on the market. The significant difference is that the newly engineered brackets and wires were designed concurrently as an integrated system.

The Ultima bracket slot is parallelogram-shaped and fits with the Ultima wire — a rectangular wire with round wire edge characteristics — to deliver direct engagement at vertical and horizontal contact points. This integrated system design virtually eliminates play, resulting in precise control of rotation, angulation, and torque. In almost all orthodontic systems, the orthodontist accepts timepoints in the treatment process where less desirable tooth movement occurs. When I was able to examine and understand the new Damon Ultima System, it appeared to be a more natural continuous movement in all three dimensions, designed to allow for a more efficient, simplified treatment while obtaining improved outcomes in a shorter time frame — all this while maintaining the core principles of PSL as it pertains to low force and friction.

There are numerous differences to the Damon Ultima System compared to current market options. The most profound is the change made to the bracket slot geometry. Until now, when variable torque brackets were used, the slot lineup between the differential torques results in vertical discrepancy along the centerline. The change in torque led to a vertical discrepancy with both positioning and expressed tooth movement (Figure 1). The orthodontist would compensate with a bend that could further complicate the issue, resulting in concerns about finishing PSL cases. The modification to the slot geometry is simple but profound. Rather than being a rectangle cut into a bracket then placed on the base, the slot is a parallelogram carved into the bracket face itself. With the new design, regardless of the variable torque bracket selected, the slot’s centerline remains level among all the brackets. This provides the orthodontist with increased bracket torque choices for creating efficient tooth movement without the undesirable side effects (Figure 2).

Key advancements in technology with this system are not only an improved bracket but also a specifically designed set of wires, which is the engine that drives the system. When the Ultima wire is paired with the newly designed Damon Ultima bracket, they work symbiotically to improve force application in all three planes of space. The wire set is designed as a rectangular wire with full rounded sides, which provides the advantages of rotation and torque control of rectangular wires and the comfort and ease of inserting a round wire (Figure 3).

These illustrations show the wire and bracket in a passive state. However, in Figure 4, the wire is paired with a variable torque bracket showing the bracket-wire interactions in an active state. The couple produced results in an improved torque expression throughout the entire Ultima wire range. The wire’s new design allows for rotation, space closure, and torque to be applied much earlier and more effectively than in the past.

A redesign of the bracket also allows for improvement in tooth movement. Changing the slot dimension to accept the Ultima wires in increasing sizes maintains passivity and ease of insertion, but eliminates much of the wire bracket play that has been previously observed. Correcting first-order movements much earlier and having precise rotation control in the beginning stages are some of the early benefits observed in my practice. Furthermore, torque expression at a greater level with the initial Ultima wires results in moving teeth purposefully from the beginning without having to wait for a previous stage to be completed.

With the engineering of the Damon Ultima System, we now have a tool that can improve the patient experience and harness technology advancement to simplify treatment and improve outcomes.

Case 1: Figures 5 and 6

Diagnosis

A 48-year-old female presented with a Class I crowded malocclusion with moderate maxillary and mandibular crowding. The facial profile was convex with a slightly retrusive mandible due to a vertical mandibular pattern. Normal lip strictures were noted with slight strain on closure due to the strong vertical pattern. A constricted arch form with tapered buccal segments resulted in poor smile width and dark buccal corridors. This, along with a reverse smile arc due to insufficient incisor eruption, resulted in poor smile esthetics.

Objectives/plan

The objectives were to create space while maintaining maxillary incisor position, to improve the smile arc by erupting incisors, and to develop the posterior segments for increased arch length as well as improved smile width. Resolving crowding through arch development with proper torque control was a key objective since incisor advancement and increased angulation would lead to further lip strain. A non-extraction plan was chosen using Damon Ultima System, along with the use of light vertical elastics for early overbite correction and smile arc improvement.

Case setup

The brackets chosen were Damon Ultima PSL brackets with neutral torque on the upper and retroclined torque on the lower 2-2. All permanent teeth were bonded, the bite was disarticulated, and 2 oz. 3/16 elastics were started from the U3’s to the L3-4’s at night only.

Case progression

Stage 1: (0-5M) Bracket placement for improved smile arc with initial 0.013 CuNiTi U/L and an early elastic protocol was started using 2.0 oz. 3/16 Class 1 triangles from the U3’s to the L3-4’s part-time to help with the eruption of the maxillary incisors and overbite. After 4 weeks, wires were changed to 0.014 CuNiTi and then to 0.018 CuNiTi extending to the U/L 7’s. Wires were again changed 4 weeks later to 0.014 x 0.0275 CuNiTi Ultima U/L. These were to be maintained for 8 weeks but were extended by a few months due to the COVID-19 shutdown.

Stage 2: (5-10M) Upon returning, the wires were changed to 0.018 x 0.0275 CuNiTi UIltima U/L. The upper 3-3 were laced to avoid space opening, and the elastics were changed to Class II full-time. A few brackets were repositioned, and the U/L 3’s were changed to proclined torque to improve angulation. The case was left for an additional 4 weeks before progressing to final wires.

Stage 3: (10-13M) The finishing wires were 0.019 x 0.0275 stainless steel (SS) Ultima upper and 0.016 x 0.0275 SS Combi lower. The patient was seen on 4-week intervals for shaping of wires and instructions for Class II box elastics to begin bite closure on the right side.

Case completion: Finishing details along with posterior elastic were completed in the last 2 weeks. The retention plan included direct placement of an upper 2112 braided SS fixed retainer and a digital scan for U/L Essix retainers with a custom-made 0.025 x 0.019 gold fixed L3-3. Retainers were provided along with tooth whitening gel with instructions for full-time wear for 1 week and then nights only moving forward.

Overview

An overview of the case resulted in the Damon Ultima PSL brackets with variable torques utilized correcting the malocclusion with resolution of the significant crowding and lack of overbite along with substantial arch development. Maxillary incisor position and angulation were maintained due to significant posterior arch development and anterior torque control. Overall, the patient was extremely compliant with elastics from the beginning to the end of treatment. From a clinical efficiency standpoint, the patient had 11 treatment visits and completed treatment in 13 months.

Case 2: Figures 7 and 8

Diagnosis

A 14-year-old male presented with a Class I constricted malocclusion with a posterior unilateral crossbite with a notable functional shift along with a partial anterior crossbite. Due to the crossbite, a slight maxillary dental cant was noted with the incisors on the left side being less erupted than the right. The facial profile was orthognathic with a well-positioned mandible. Radiographic analysis shows well-positioned maxillary and mandibular incisors. Lips were well supported, but slightly retruded relative to the facial structures. Additionally, tapered buccal segments were observed, and a poor smile arc was noted due to insufficient incisor display when smiling.

Objectives/plan

The objectives were to maintain maxillary incisor position through torque control of anterior, to improve the smile arc by erupting incisors, and to develop the posterior segments for improved smile width. A non-extraction plan using Damon Ultima System was chosen along with the use of posterior crossbite elastics for early posterior development and crossbite correction.

Case setup

The brackets chosen were Damon Ultima PSL brackets with neutral torque on the upper and lower. All permanent teeth were bonded with buttons on the palatal of the U6’s for crossbite elastics. The bite was disarticulated, and 3.5 oz. 3/16 elastics were started from the U6’s to the L6’s.

Case progression

Stage 1: (0-5M) Bracket placement for improved smile arc with initial 0.014 CuNiTi U/L and an early elastic protocol was started using 3.5 oz. 3/16 Class crossbite elastics from the U6’s to the L6’s full-time. The occlusion was disarticulated by placing bite stops on the U6’s to reduce the effect of incline planes and allow for easier correction of the crossbites. After 4 weeks, wires were changed to 0.018 CuNiTi extending to the U/L 7’s. Wires were again changed 4 weeks later to 0.014 x 0.0275 CuNiTi Ultima U/L. These were to be maintained for 8 weeks but were extended by a few months due to the COVID-19 shutdown.

Stage 2: (5-10M) The next visit back, wires were changed to 0.018 x 0.0275 CuNiTi Ultima U/L. The upper 3-3 segment was laced to avoid space opening, and the crossbite elastics were discontinued since the corrections were observed. A few brackets were repositioned, and the U1’s were changed to proclined torque to gain inclination. The case was left for an additional 4 weeks before progressing to final wires.

Stage 3: (10-14M) The case was finished in 0.019 x 0.0275SS Ultima upper and 0.016 x 0.0275 SS Ultima lower. The patient was seen on 4-week intervals for shaping of wires and instructions for vertical elastics to begin bite closure after crossbite correction. Light buccal root torque was added to the final wires; however, the posterior bite stops were not removed until case competition resulting in lack of occlusion of the U6’s. These were corrected by changing the position of the U/L 6’s in the digital software prior to fabrication of retainers.

Case completion: Shaping of archwires and minor details, along with posterior elastic, was completed in the last 2 weeks. The retention plan included direct placement of the upper 2112 braided SS fixed retainer and a digital scan for U/L Essix retainers with digital correction of the 6’s with a custom-made 0.025 x 0.019 gold fixed L3-3. Once the 6’s have improved occlusion, the case will be scanned for fabrication of final Essix retainers.

Overview

An overview of the case resulted in the Damon Ultima PSL System with proclined torque on the upper 1’s, and neutral torque on the lower incisors show correction of the anterior and posterior crossbites, improvement of arch form with correction of the functional shift. Maxillary incisor position and angulation were maintained even with the significant amount of posterior width achieved while the smile arc and width were enhanced, resulting in a much more visible and natural smile. After evaluating the case, some improvements would have been observed if I would have used retroclined torque on the U3’s and removed bite stops earlier in treatment, resulting in better angulation of the 3’s and a more settled occlusion of the 6’s, respectively. From a clinical efficiency standpoint, the patient had 11 treatment visits and finished treatment in 14 months.

Conclusion

The two case examples presented highlight the outcomes that become possible with a commitment to improved patient experiences by harnessing technology advancements. It was impressive to see the effects of the Damon Ultima System. With early rotation correction and improved torque control with the Ultima wires, the final wires required very few adjustments. The benefits to the patients were less discomfort, shorter overall treatment time, and a fantastic outcome. Just a short time ago, a 27-month treatment plan was acceptable for one case; now we can compete two challenging cases in the same time combined. This truly demonstrated how we are progressing as a profession, and how technology and the pursuit of improved patient care are really improving the patient experience. We live in a world where constant change and improvements, and “upgrades” are synonymous with progress. By continually advancing our profession and keeping it at the forefront of technology, we also help ensure that the orthodontist will be the best option when it comes to choosing a provider to deliver orthodontic treatment.