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Three-dimensional orthodontic treatment has become thestandard of care in our orthodontic practice. In order for this trans-formation to have taken place in our practice over the years, therehave been three major software applications that we have had toimplement: i-CAT cone beam computed tomography (CBCT),Dolphin 3D and SureSmile. Prior to the implementation of thesesoftware applications, my experience with lingual treatment hadbeen limited to two full orthodontic cases back in my residencydays at Northwestern University, which had convinced me that Iwould never want to treat another full lingual case ever again. Isn’tthat the beauty of technology? The development of a self-ligatinglingual bracket, Innovation L (Dentsply GAC), and its ability to beutilized with SureSmile’s software applications, has created a cost-effective and easy-to-use aesthetic treatment option that I can nowoffer my patients. In this article, I will discuss a patient who I

treated with SureSmile (upper lingual and lower labial) in combi-nation with i-CAT, Dolphin 3D and orthognathic surgery.

Patient InformationThis patient presented to me at his new patient examination

in August of 2009 as an adult male age 27 and a half. He washealthy with one exception: He had been diagnosed withobstructive sleep apnea (OSA) approximately two years prior,which had been confirmed with a sleep study by his physician.For the past two years he had been treated with a dental sleepappliance made by a general dentist who specializes in sleepmedicine. His chief complaint to me was that although he hadgood success in the beginning with the dental sleep appliance,over time, he had noticed a change with his bite and then hebegan to develop temporomandibular joint (TMJ) dysfunction

by Ed Lin, DDS, MS

Reprinted with permission of Orthotown Magazine ©2012

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issues with clicking and facial pain. As a result, he began toresearch other treatment options for OSA and came acrossorthodontics and orthognathic surgery as a viable option thatcould potentially cure his OSA.

Diagnosis and EtiologyIntra-oral examination revealed a Class III malocclusion. He

had an overbite (OB) of zero percent and overjet (OJ) of -2mm.Minor lower incisal wear was present due to his OB/OJ relation-ship. Arch length deficiencies were present of 6mm in his max-illary arch and 4mm in his mandibular arch. Arch forms wereasymmetric and tapered with bilateral posterior crossbite pres-ent. Periodontal evaluation revealed overall normal and healthygingival tissue. However, there was some minor gingival reces-sion present in his lower anterior dentition, which I believe wasdue to forces translated to his anterior dentition from the wearof his dental sleep appliance (Fig. 1).

Frontal facial evaluation revealed a balanced and symmetricalfacial pattern. Profile facial evaluation revealed a straight profilewith normal chin. His nasio-labial angle was obtuse at 130degrees. Both upper and lower lips were competent at repose.However, his lower lip was slightly protrusive in comparison tothe position of his upper lip. A frontal smile evaluation revealedacceptable upper and lower smile lines with buccal corridors pres-ent. There were no maxillary or mandibular cants present (Fig. 1).

A single i-CAT CBCT scan was taken (13cm height at 0.4voxels for 10 seconds). Using Dolphin 3D, cephalometric analy-sis revealed a Class III skeletal relationship with ANB=0 due toa mid-face deficiency with SNA=78 (Fig. 2).

Panoramic evaluation from the CBCT scan revealed that allthird molars had been extracted. Alveolar bone height in bothmaxillary and mandibular arches looked healthy and within nor-mal limits. There were no other significant findings (Fig. 3).

Tomogram analysis of his TMJs revealed normal and healthylooking mandibular condyles with no evidence of degenerativejoint disease (Fig. 4).

An airway analysis utilizing Dolphin 3D from the CBCTscan revealed Airway Area=1068.0mm2 and Airway Volume=25,361.8mm3 (Fig. 5).

Treatment SummaryThis patient was referred to an oral surgeon, Dr. Vijay Parmar,

for an orthognathic surgical consultation. The treatment plan rec-ommended for the patient consisted of full fixed orthodontictreatment in combination with two-jaw orthognathic surgery forcorrection of his malocclusion and OSA. The patient was alsointerested in an aesthetic treatment option for his orthodontictreatment. As a result, the patient elected to pursue lingual treat-ment in his upper arch and labial treatment in his lower arch withSureSmile. From the start of his orthodontic treatment until hissurgery, the patient utilized a continuous positive airway pressuremachine (CPAP) for management of his OSA, although he didhave some difficulty tolerating the CPAP machine.

In September of 2009, 0.018 In-Ovation L fixed lingualappliances were placed in his maxillary arch for U7-7 and In-Ovation C and R fixed labial appliances were placed in hismandibular arch (Dentsply GAC) for L7-7 using an indirectbonding technique. On this same day, the patient also began theSureSmile process, which is referred to as a “Fast Track” among

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SureSmile users (Fig. 6). After the brackets were placed, all bracketdoors were closed in preparation for the i-CAT/SureSmile CBCTscan. A wax bite was taken with condyles seated in the glenoidfossa and ~3mm of separation between maxillary and mandibulardentition. Without archwires and with the wax bite present, the i-CAT/SureSmile CBCT scan was then taken with an i-CATClassic machine (8cm height at 0.4 voxels for 10 seconds). It isnecessary to have separation between the maxillary and mandibu-lar dentition with the wax bite to enable SureSmile’s digital labtechnicians to create the clinical crown anatomy in its SureSmileCAD/CAM software application. An initial G&H round 0.016CuNiTi mushroom-shaped, lingual archwire was placed in hismaxillary arch and an initial Bioforce Sentalloy rectangular 0.018x 0.018 straight archwire was placed in his mandibular arch.Open coil springs were also placed distal to his UR2, UL2 to cre-ate spaces in preparation for his orthognathic surgical procedures.

A SureSmile pre-surgical plan was created treating the maxil-lary and mandibular arches independently for ideal leveling andaligning of all rotations, parallelism of all crowns and roots, and ofthe marginal ridges (Fig. 7). In November of 2009, six weeks afterbeginning his orthodontic treatment, the patient returned forplacement of his robotically bent initial SureSmile archwires (max-illary - 0.016 x 0.022 lingual CuNiTi and mandibular – 0.017 x

0.025 labial CuNiTi) (Figs. 8 and 9). In January of 2010, thepatient returned for placement of his second maxillary SureSmilearchwire (0.017 x 0.025 lingual CuNiTi). In March of 2010, thepatient returned and using SureSmile’s software applications at theclinical chair, minor virtual wire modifications were made to levelsome posterior marginal ridges and for torque correction of hisUL7 to ideal. These SureSmile wires (maxillary – 0.017 x 0.025lingual CuNiTi and mandibular – 0.017 x 0.025 labial CuNiTi)(Figs. 10 and 11) were then inserted three weeks later.

In May of 2010, pre-surgical records were obtained for thepatient and plastic labial buttons were placed on the maxillarydentition for vertical elastics to be worn after his surgery, sincethis patient was being treated with lingual fixed appliances (Fig.12). The appropriate virtual treatment outcome for his orthog-nathic surgical procedures was then determined between the oralsurgeon, Dr. Parmar, and myself utilizing Bill Arnett’s SurgicalModule in Dolphin Imaging (Fig. 13). These measurements werethen transferred over for model block surgery to create an inter-mediate surgical guide to be utilized during the surgery for repo-sitioning of his mandible and maxilla. In July of 2010, the patientunderwent two-jaw orthognathic surgery. The orthognathic sur-gical procedures consisted of surgery first in the mandible withmandibular advancement and counter-clockwise rotation of the

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mandible, in combination with a maxillary three-piece osteotomy with expansion and maxillaryadvancement. Rigid fixation was utilized in com-bination with vertical traction elastics to stabilizethe osteotomies. There was no final splint utilizedpost-surgery. The patient returned for a post-sur-gical evaluation two weeks after his surgery (Fig.14). The patient stated that there was little post-operative pain and there was only slight numbnessin the maxillary anterior tissue. A second post-sur-gical evaluation was done two weeks later inAugust of 2010. The patient stated that he waseating very comfortably and that his breathingand sleeping had significantly improved.

In September of 2010, a second i-CAT/SureSmile CBCT scan(8cm height at 0.4 voxels for 10 seconds) was performed for thepatient to capture the patient’s occlusion after orthognathic sur-gery. A post-surgical SureSmile plan was created for the patient(Fig. 15). The robotically bent SureSmile wires (maxillary – 0.017x 0.025 lingual CuNiTi and mandibular – 0.017 x 0.025 labialCuNiTi) were then inserted in October of 2010. In January of2011, the patient’s orthodontic treatment was completed with theremoval of his fixed orthodontic appliances. He was then movedinto retention with an Essix ACE retainer with full-time wear andan L3-3 fixed lingual retainer wire. Three months later, the patientreturned for final records and the wear of his upper Essix ACEretainer was reduced to bedtime only (Fig. 16).

Summary and ConclusionsTotal treatment time for the patient was 16 months and six

days. Total number of appointments for his entire treatment was18, including four emergency appointments to replace two brack-ets and two plastic buttons. The patient states that his OSA hasbeen completely corrected and he sleeps very comfortably at night.He no longer needs a dental sleep appliance or CPAP machine. Avideotaped personal testimonial was also taken describing his expe-riences during the course of treatment. A follow-up sleep study wasperformed by his physician to confirm correction of his OSA. Apost-surgical airway analysis utilizing Dolphin 3D from the post-surgical i-CAT/SureSmile CBCT scan revealed increases in AirwayArea=1219.7mm2 from 1068.0mm2 and Airway Volume=28,936.9mm3 from 25,361.8mm3 (Fig. 17). As a result, his treat-ment has resulted in an increased Airway Area and Airway Volumeof 14 percent. A final cephalometric analysis revealed that ANB=2

and had been corrected to a Class I skeletal relationship. FinalSNA=82 and his orthognathic surgery had corrected his mid-facedeficiency to within normal limits (Fig. 18).

By combining different state-of-the-art 3D software applica-tions that are available to our orthodontic profession today (i-CAT,Dolphin 3D and SureSmile), this patient’s treatment was completedentirely with 3D orthodontics. Utilizing self-ligating lingual brack-ets in his maxillary arch in combination with SureSmile CuNiTiwires provided the patient a cost-effective and easy-to-use aesthetictreatment option with complete control during treatment.SureSmile is currently the only lingual 3D software treatment appli-cation that gives the doctor and patient the option of treating onlyin one arch or both arches. Because we are utilizing CuNiTi wireswith self-ligating lingual brackets throughout the course of his treat-ment, this makes treatment for the clinician much easier and moreappealing as there are no wire bends that need to be made manuallywith pliers and engagement of lingual CuNiTi wires with lingualself-ligating brackets is not a difficult thing.

As I mentioned at the beginning of this article, I neverthought I would be treating patients ever again with lingualappliances because of my experience with lingual during myorthodontic residency. However, technology has changed the waywe all practice. Prior to SureSmile with lingual, I would havenever thought it possible to be able to complete a full lingual casein only 16 months. But to do this in combination with two-jaworthognathic surgery is truly amazing! Without a doubt, lingualtreatment with SureSmile has been a big adjunct for me in mypractice over the past two years. I would strongly encourage mycolleagues to evaluate this as aesthetic treatment in strongdemand with our patients. Who knows what technology willbring next! n

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Author’s BioInternationally recognized speaker, Dr. Ed Lin, is a full-time practicing orthodontist and partner at both Orthodontic Specialists of Green Bay(OSGB), in Green Bay, Wisconsin, and Apple Creek Orthodontics (ACO) in Appleton, Wisconsin. Dr Lin received both his dental and orthodonticdegrees from Northwestern University Dental School (‘95 - DDS and ‘99 - MS).

orthotown.com \\ SEPTEMBER 2012 41Reprinted with permission of Orthotown Magazine ©2012

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