Orthodontics In Interview: Aligners, Limited or Just Misunderstood? tommaso castroflorio

“The biggest difference in overcoming the limitation (of aligners) is to understand how to control aligner deformation”

“We need to improve the available knowledge about aligners, because we need to control the companies, we do not need companies controlling us”

“I think you can treat also complex cases, in my practice I treat extraction cases”

“There are limitations in every technique, I think that the good orthodontist understands how to manage the limitation and how to overcome them”

“Large mass 3D printing will represent an important evolution in orthodontics, aligners and braces”

Tommaso explores the current understanding ofaligners, there limitations in terms of an appliance and scientific research. We explored the debate of aligners treating complex cases, why attachment designs still have limitations, and the role of aligners as functional appliances. We discuss emerging concerns of micro and nano-plastic toxicity andenvironmental concerns of aligners.

TIMELINE

00:00:00 Introduction of Dr Tomasso Castroflorio

00:00:51 Tomasso's Early Experiences with Aligners

00:08:21 What are the Limitations of Aligners?

00:11:24 How do we Overcome Limitations with Aligners?

00:17:59 Should Aligners be Restricted to Mild to Moderate Cases?

00:20:22 Research IndicatesAligners Only Tip Teeth into Extraction Sites, Do you Agree? 00:25:50 Importance of Visualization in Orthodontics?

00:29:27 Are Functional Appliance Aligners Advantageous over Conventional Functional Appliances?

00:35:08 Has There Been Over-emphasis on Attachment Design?

00:44:18 What are the Consequences of Microplastics and Aligners?

00:50:32 What is the Future of Aligners?

00:53:54 Who do you Admire the Most in Orthodontics

00:55:36 Advice from Tomasso to all Orthodontists

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https://orthoinsummary.com/orthodontics-in-interview-aligners-limited-or-misunderstood-tommaso-castroflorio/

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Farooq Ahmed

Join me for a summary of recent long-term research of resorbed teeth due to impacted canines. This podcast is based on an excellent lecture by Julia Naoumova delivered at last year’s British Orthodontic Conference. Part 2 with focus on the prognosis of resorbed teeth from impacted canines, and follows on from part 1 with explored outcomes of open Vs closed exposures of impacted canines – see here for part 1.  

Root resorption of incisors reported at 19-67% Erikson 2000 Walker 2005, Mitsea 2022

Anna Dahlén and Julia Naoumova 2024 retrospective CBCT study n =27 incisors

Mean   Follow-up average 9 years (5.5-14.6)

Patient reported outcomes

• Survival 100%

• Horizontal grade 3 moderate resorption n=17  (resorption inner dentine not involve pulp moderate)

• Horizontal grade 4 severe resorption n=12 (pulp exposed severe)

• Vertical grade 3+ severe resorption n=7 (resorption 2mm-1/3rd moderate)o

• Vertical grade 4 extreme resorption n = 1  (resorption 1/3rd +)

• No significant difference in any grade of resorption long term of the following:

• Symptoms 

• Mobility and ankylosis

• Discolouration

• Increase gingival pocketing but not clinically significant 

• RR horizontal changes with time 

• No change 81%

• Worse 4%

• Improve 15%

• RR vertical changes  with time

• No change 43%

• Worsen 57%

• Expected as had orthodontic treatment as well

Previous research 

• 1-23 years Survival 93-100% Falahat 2008 , Bjerklin 2011, Becker 2005, Jönsson 2007

• Jönsson 2007 showed grade 1 mobility when root length < 10mm 

Conclusion:

Extraction of asymptomatic based purely on root resorption should be routinely performed

Paper by Anna Dahlén and Julia Naoumova 2024 

Longitudinal study of root resorption on incisors caused by impacted maxillary canines—a clinical and cone beam CT assessment 

https://doi.org/10.1093/ejo/cjae052

Join me for a summary of the management of impacted canines, the latest evidence regarding different techniques for alignment. This podcast is based on an excellent lecture by Julia Naoumova delivered at last year’s British Orthodontic Conference. 

Part 1 will focus on recent findings of a modified open exposure technique Vs closed exposure, in terms of duration but also other key outcomes, health, pain, use of analgesics,  time absent from school and costs. The next episode, part 2, will look at the prognosis of resorbed incisors related to impacted canines long term. 

Previous research  no difference between closed Vs open exposure for alignment, aesthetics, treatment time, surgical success, treatment times. Limited to 2D views Parkin 2017, Sampaziotis 2018, Cassina 2018. 

Questionnaire of current decision making of open Vs closed: n=48 orthodontists = current clinical decision making by orthodontists based on preference Naoumova 2018

Multicentre RCT Margitha Björksved 2018, 2021

• Modified open exposure with Glass ionomer OPen Exposure, first described by Nordenval 1999

• 6/12 of spontaneous eruption

• Traction with orthodontic appliances

Results

• Total time: no difference 26 months (95% CI −3.2 to 2.9, P = 0.93)

• Canine eruption time: Open exposure quicker by 3 months 8.5 months Vs 11.5 months (95% CI 1.1 to 4.9, P = 0.002). With no traction in open exposure group 

• No difference in periodontal status, root resorption, surgery time, complications, 

• Pain:  greater in closed group

• Greater pain with bilateral open exposure

• Closed exposure more painful applying traction 

• Analgesics use (preliminary data):

• Day 1 nearly all patients use

• Day 5 drops to less than 50% of patients use

• Day 10 most have stopped taking analgesics

• Costs: – no difference 

• €3,400  healthcare costs

• €6,300 including patient costs

• Missed days of school (preliminary data)

• Day 1 -  76% open Vs 65% closed exposure 

• Day 2 -  3% open Vs 6% closed exposure

Open exposure with GOPEX Not appropriate for:

• Close to adjacent tooth, to avoid material on adjacent teeth

• Very high canine position 

• Older patient – start traction straight away, probability of ankylosis increases Cernochova 2024

• 1% at age 15

• 4% at age 20

• 14% at age 25

• 97% at age 45

Conclusion:

• Both open and closed techniques are viable, however with open exposure of GOPEX technique the canine erupts spontaneously and quicker

• Less pain with open exposure unless bilateral

• Most patient will miss 1-2 days from school 

• Pain relief common for the first 5 days, but maybe used until day 10

Papers

Open vs closed surgical exposure of palatally displaced canines: a comparison of clinical and patient-reported outcomes—a multicentre, randomized controlled trial 

Margitha Björksved

Open and closed surgical exposure of palatally displaced canines: a cost-minimization analysis of a multicentre, randomized controlled trial 

Margitha Björksved

Join me for a summary looking at remote monitoring in orthodontic clinical practice, and if it can improve, quicken and enhance orthodontic clinical practice. This podcast is based on an excellent webinar by Jonathan Sandler and Juan Carlos Varela, as part of the Angle-net webinar series. I discuss how Dental Monitoring works, the proposed advantages and a review of the emerging research on this innovation in orthodontics. 

What is Dental Monitoring?

How does it work?

What do patients think of it?

Patients attitudes to remote monitoring

Does it reduce appointments and make treatment quicker? Sangalli 2024

Are treatment outcome better (aligners)? 

Is oral health better? 

Other innovations with remote monitoring?

Remote STL files

Is Dental Monitoring accurate? Ferlito 2022

Conclusion

Areas which are of concern

Other ways to reduce time?

“We do not accept the weaknesses of out appliances as absolutes, but rather we adjust out treatment mechanics to account for them Mazyar Moshiri,

“it's a platform for mass customization”

“I think Lightforce system has more friction than it should right now.”

“We operationalize great outcomes.”

“People that need to have a Cochrane review to prove to themselves the sky is blue, those are not the people that should be using Lightforce right now”

Alfred and I discuss his digital bonding system, Lightforce, we explore the product as well as the strength of the claims around it. Alfred replies to criticisms of the product as we explore the emerging evidence of his digital bonding system. 

Alfred gives his opinion on the digital evolution within orthodontics, we have a candid discussion on the use of digital orthodontics and where there are still areas of significant improvement needed.

Join me for a look at CBCT and its use in the diagnosis of the transverse problem, and if it offers the solution to the debated topic. The podcast is based on a lecture by Chun Hsi Chung at this year’s AAO and appraises established methods of assessment, the Curve of Wilson and the WALA ridge line through the lens of a CBCT, as well as how to use a CBCT to assess the maxilla and mandible, which although revealed an ideal measurement, may not be telling the full story.

What is ideal?

inclination 

Curve of Wilson – CBCT study 

Andrews WALA ridge 2000

Normal width  CBCT

CBCT age 13 N = 79 Miner 2012

CBCT Age 22.7 years Koo 2017

CBCT 56 adults normal occlusion  Lee 2022 PENN STUDY

Without cbct can transverse diagnosis occur?

Issue with CBCT for diagnosis

Issue with study model transverse analysis from 4mm at the gingiva

Join me for a summary looking into the increasingly popular

OSA - Defined upper airway dysfunction causing complete or

Sleep = Slow wave sleep – constructive phase of sleep

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Outcomes to paediatric patients of SDB: (AASM)

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First line medical treatment – adenotonsillectomy 

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Effect palatal expansion

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Expansion other outcomes -  school performance  Bariani 2024

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Mandibular advancement

Move mandible forwards and open space behind the tongue – oropharynx

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Orofacial features in children with obstructive sleep

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AADSM 2024 – consensus statement

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More about OSA?

To hear more about OSA, please check out the last interview

Interview

Join me for a summary looking at The Posterior Bolton Discrepancy,

Wayne Bolton established the Bolton’s ratio:

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What is the posterior Bolton’s ratio

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Ratio confirmed by Mongillo 2021

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The effect of 4 premolar extractions on the posterior

Study: Mongillo 2021 (extraction of all 4s) Holton 2023 (extraction

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Clinical options

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 Join me for a look into a recent digital innovation within

What is Lightforce

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Stages

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Other advantages

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What are the proposed advantages and claims around Lightforce

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Proposed advantages and claims around Lightforce ithout

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What are my thoughts?

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Papers and videos on Lightforce

https://www.jco-online.com/media/42415/2023_09_500_waldman.pdf

JCO retrospective study

https://www.jco-online.com/media/43897/2024_05_273_wheeler.pdf

Youtube videos from Lightforce company, Alfred Griffin

https://www.youtube.com/watch?v=zSNkYVgZ69I&t=2s&ab_channel=People%2BPractice

Disclaimer

The podcast is opinion and may not be 100% accurate or

Contributions

Contents and editing

Farooq Ahmed