CONTENTS Introduction Recent advances in Brackets Recent advances in Bonding materials Recent advances in Orthodontic wire Recent advances in Software Recent advances in Digital orthodontics Recent advances in appliances Recent advances in robotics Recent advances in Bioengineering Conclusion ReferencesIntroduction There has been tremendous progress in orthodontics since Edward Angle first popularised the fixed orthodontic appliance, Recent years have seen an increased demand for orthodontic treatment from both adolescents and adults , and in addition, patient and clinician expectations of treatment outcomes also continue to rise . Technological & material advancements in orthodontics has made possible a constant improvement in the quality of orthodontic treatment ultimately benefiting the patient.Technological infusions that have been game changers in orthodontics A 1 R ‘Apps imaging Rapid Prototyping ‘A number of Apps om the Android and 10S scBCTs Various applications in Orthodontics platiors for management , diagnostics, “Facial 3D WL Scans “Aigner fabrications ‘communication and professional interactions "3D Photography Surgical splints. Pl refer to Table 2 “intra Oral Scanning "Bruxism splints *E Models “Auto transplantation templates Appliances/Adjuncts. Volumetric Data Sets and Integrated “Casemired epplences “CAD CAM Customized Appliances Wraps: “Indirect bonding trays “Abgners "Professional Compaities/Softwares that “Diagnostics for impacted teeth “Robotic Archawires integrate data and provide 30 volumetric *3 D printed kaws (orthognathics) "Customized Adjunets through digital Data Sete-great potential for research *Cranolaczal/Cieft Planning workflows {and planning in erthognathics *3D printed Functional Appliances “Integrated Volune Wraps of various. Imaging modalities into a single file that can provide comprehensive informationRecent advances in BracketsFabrication of orthodontic brackets * Anew material containing hard alumina nanoparticles embedded in polysulfone wes introduced in year 2012 (UC3M) for making orthodontic brackets. * The rigidity of the material increases the strength of the brackets & also reduces frictional and mechanical resistance of the brackets to orthodontic wires along with maintaining the transparency of the brackets. * Coating with NPs also improve their properties like: O Titanium dioxide because of its photocatalytic properties QO Ni-P -WS2 nanoparticles to Reduce friction, Q Zno and Cuo nanoparticles for antibacterial propertiesSmart brackets with nanomechanical sensors * Knowledge of the 3D foree-moment systems applied for OTM is important for the predictability of the course of tooth movement & reduction of traumatic side effects. + Nanomechanical sensors can be fabricated and be incorporated into the base of orthodontic brackets in order to provide real-time feedback about the applied orthodontic forces. | * Allows the orthodontist to adjust the applied foree to be within | biological range to efficiently move teeth with minimal side effeets. , sAPC —Adhesive Coated Appliance System + The only orthodontic bonding system that precoats each bracket with adhesive. APC” Flash-Free Adhesive System —5 Steps APC™ I/ PLUS Adhesive Systems — 6 Steps pe A ‘Traditional Light Cure Bonding Systems —11 StepsDr. Clarke Stevens, a practicing orthodontist from Omaha, wanted kids to be able to express themselves with their braces. Colored bands were already available, so he decided to focus on the brackets that attach to the teeth, and WildSmiles braces were the result. Different bracket shapes can be combined, and colored bands can be added, giving child the ability to be creative with their smile.Decreased plaque accumulation compared to conyentional brackets & decreased friction between bracket and arch wire Decreased chair time for arch wire changes Use of light forces & Possibly faster tooth movementRecent advances in Bonding materialsteak pea Peas 6" Generation -Self etching primer we bomioue on fete aes ving + Eliminate wash & dry step after eos oonachot ro henna | Sasa etching , so collagen collapse by air ma on & m fa mo ome drying is avoided. 2% wee oe sme oo ma a Fa —— Uitte * Hydrophilic primers- Ortho ‘ie foro | Sense a | ae Solo, Assure, MIP bond ina slightly Coie ate e wet environment. 7" Generation - They are first , No mix self etch adhesive provided in single container combining all steps —Etching , priming , adhesion in bonding . 8" Generation — Voco America introduced Futurabond DC ( nano-sized filler -12 nm that increases penetration of resin monomer & hybrid layer thickness )Color Change Adhesive Color changing adhesive for enhanced bracket positioning and flash clean-up One of the most advantage of these CCAs is visibility of any adhesive remnant at bracket seating as well as identifiable cleanup of adhesive remnants after debondingNanocomposites And Nanoionomers + Nanoparticles of reduced size are being used as fillers te reduce polymerization shrinkage and to improve the mechanical properties of strength . ‘Techniques Flame pyralysis, Types of fillers: Silica nanosized filler Flame spray pyrolysis, + Nanoclusters Titanium dioxide and Sol-gel processes. * Nanoparticles Nano zirconia * Uysal et al (2010) - evaluated the bond strength of nanocomposites and nanoionomers shown that these nanomaterials may be suitable for bonding in orthodontics as they fulfill the shear bond strength ranges for clinical acceptabilityme Janocomposites and nandionomers for bracket bonding, Filtek Supreme Premise CeramX Ketac N 100 Type Nanofilled. Nanohybrid Nanohybrid Ormocer-based, nanocetamic composite Light cure resin modified GIC ‘Manufacturer 3M ESPE, St Paul, MN, USA. Kerr/Sybron, Orange, CA, USA Dentaply DeTrey, Konstanz, Germany 3M, ESPE, St Paul, MN, USA. 15Recent advances in Orthodontic wireCopper NiTi alloy wires * Introduced by Rohit Sachdeva and Suchio Miuasaki in 1994. This alloy contains 50%-60% Of copper and 0.2%-0.5% chromium , in addition to Ni-Ti added to wFTorelaret ae bring down the TTR to oral temperature. ab aa aT ae * Copper is added to enhance the thermal properties of eed a nickel-titanium alloy. Super cable Hanson 1993 - superelastic NiTi coaxial wire * Seven Niti strands woven together in a long, gentle spiral to maximize flexibility and minimise force delivery + This wire was specially developed to be used with SPEED self-ligating bracket sysrem.Nickel-free austenitic SS & TMA Wires * — The steel is alloyed with 15%-18% chromium, 3%- 4% molybdenum, 10% -14% manganese and about 0.9% nitrogen to compensate for the nickel. These wires are available as a single-, triple- or six-sttand SS wires and TMA (Connecticut New Arch ,CNA) arches, for example Noninium or Rematitan wires by Dentauram Titanium-niobium-aluminium (Ti-Nb-Al) alloy * Ithas the best mechanical performance among these nickel-free shape memory and superelastic alloys, was developed as a result of advances in processing technology. * The Ti-Nb-Al wires can be used as a substitute for Ni-Ti wires. + The Ti-Nb-Al expansion spring exerted lighter and continuous force and facilitated safe and efficient tooth movement.Bioforce archwire Superelastic shape memory nickel titanium wire that provides gradually increasing forces from anterior ( Light force to incisor & canines , moderate forces to bicuspids) to posterior segment ( Molars- Physiologic Heavy forces), all within one archwire. By ion beam implantation process , nitrozen replaces nickel on the top and changes the surface to titanium nitride. BioForce wires with [on Cuard result in a significant reduction in friction during tooth moyement.Dual flex archwire + The Dual Flex-l: It consists of an anterior section made of 0.016-in. round titanal and a posrerior section made of .016-in, round steel + The Dual Flex-2: It consists of a flexible front segment composed of a 0.016 x 0.022-in. rectangular titanal and a rigid posterior segment of round 0.018-in. steel + The Dual Flex-3: It consists of a flexible anterior part of a 0.017 X 0.025-in. titanal rectangular wire and a posterior part of 0,018 square steel wire. * The Dual Flex-2 and 3 wires provide anterior anchorage and contro! molar rotation during the closure of posterior spaces and initiate considerable torque in the anterior segment.Optiflex wires + Talass introduced the first optiflex wire (Ormeo,USA) to combine optimum mechanical properties with a highly aesthetic appearance. sng: smen Roe (sow Coney Nyon pyres. Plastic-coated NiTi * Plastic covered, tooth coloured superelastic nickel-titanium archwires are available as Nitanium (Tooth Tone). + Itis claimed to have lower friction and blends with natural dentition as well as ceramic, plastic and composite brackets. It is stain and cracks resistant.Marsenol - Tooth colored Nickel Titanium wire coated with/an elastomeric poly tetra fluroethy! emulsion exhibiting all the same working characteristics of an uncoated super elastic Nickel Titanium wire, manufactured by Glenroe technologies Fiber reinforced composite arch wires - fabricated using a procedure called pultrusion. Fiber bundles are pulled through an extruder, in which they are wetted with a monomer resin & then cured with heat and pressure resulting in polymerization * Circular or rectangular wires are formed during curing. This may be shaped into a different morphology by further curing, a process known as beta staging. + Property - High elastic recovery, high tensile strength, low weight, excellent formability, excellent esthetics because of their translucencyFabrication of Hollow Wires )2 nanoparticles * Spherical NiTi particles are coated over a textile or a polymer fiber via electrospinning. Then, the fiber is removed from inside thus producing a hollow wire. Advantage : + Possibly reducing the material needed for the wire production. + They may deliver lighter and more continuous force. + The bending properties can be customized by inserting another wire into the hollow core.Shape memory polymers Carbon Nanotubes or Nanofibers & organic-exfoliated Nanoclay are used as fillers. SMPs materials have the ability to memorize a macroscopic equilibrium shape and then be manipulated and fixed to a temporary shape under specific conditions of temperature and stress. Polymers activated by the body temp or by light (photoactive nanoparticles). In addition, the SMP materials are clear, colourable, ead and stain resistant, providing the patient a more “S. : QS aesthetically appealing. = = remnant sn 24Recent advances in SoftwareOrthodontic apps for smartphones Operating —_-—Gategory Number Operating Gategory Number system system Tos Cinicians app "Aro ‘CamntEanS app ‘Clinic apps/practice 89 ‘Clinic appsfpractice 95 ‘management ‘management ‘Publications ouenaisiiaganines 2 Publications/jourmals/magazines 15 ‘Orthodontic produets 10 Orthodontic products 7 Apps aiding in diagnosis, a Apps aiding in diagnosis 10 ‘Onhodontic conferences 6 Orthodontic conferences ‘4 Tooth ratio calculators 2 Inger saee calccranes: 2 ‘Orthodontic news. Patient apps: ‘Orthodontic education ‘Reminding patents about ‘elastic wear ‘Reminding patients about 2 aligner wear Deating with arthodontic 2 emergencies ‘Progress tracker 2 Total 8Artificial intelligence and Machine learning + Alas ascience is very broad and encompasses various ficlds, including reasoning, natural language processing, planning, and machine learning (ML) * — Work in AI started back in 1943,but it was not until 1956 that the term “Artificial intelligence” was first used during a conference held at dartmouth college. + A few years later, the term “machine learning” was officially applied to a checkers-playing program, considered one of the first successful self-learning tools. + ML is not intended to mimic human behavior ,it supplements human intelligence by performing tasks that are beyond human capabilitiesML FOR DIAGNOSIS AND ORTHODONTIC TREATMENT PLANNING Extraction decision making predicting the extraction decision 80% (Wang et al 2010) and 93% (Jung SK et al 2016, Tang T et al 2019 (Anchorage requirement — 83% ) 5—15% better accuracy of landmark detection with ML (Leonardi et al 2008) Determining the growth status of patients (Buschang PH et al 2017) Overlook diagnosing a lesion, tumor & canine impaction by OPG , lateral ceph (Laurenziello M et al 2017) & CBCT (Yilmaz et al 2017 ) Predicting the size of unerupted teeth (Moghimi S, et al 2017) To determine the forces needed to align teeth (Omran LN, et al 2018)+ Used to predict the change in lip curvature after orthodontic treatment with or without extractions. (Nanda SB et al 2017) + Predictions of treatment outeomes in Class I and Class III patients (Zarei A et al 2006) * To classify patients craniofacial growth as either normal or abnormal (Perez SV et al 2016) Scope and performance of artificial intelligence technology in orthodontic diagnosis, treatment planning, and clinical decision-making - A systematic review Conclusion: The results from these reported studies are suggesting that these automated sys- tems have performed exceptionally well, with an accuracy and precision similar to the trained examiners. ‘These sys- tems can be of great value in orthodontics. It iceeiibi bs cies Ha “Al models are limited and ERAMECMNNEENNEN «© sre dls they should be aed only ofter cacfl $.8, Khanagar et al considerations. Like any statistical model, the ML May 2020 algori s are based on assumptions and have limitations.Recent advances in Digital orthodonticsDigital technology in orthodontics It started to make its way into dental and orthodontic offices with the introduction of computerized scheduling in the 1974. In last three decades most offices have now become paperless , digital photography and 3D radiography & intraoral scans To perform virtual treatment planning as well as translate the plans into treatment execution with digitally driven appliance and placement using various CAD/CAM techniques , indirect bonding trays and also custom made brackets & to robotically bent wires.Digital and computerised cephalometrics + Robert Murray Ricketts (father of computerised orthodontics) spent a significant time in the development of computerised cephalometric systems . integration of growth prediction data and visual treatment objectives (VTO), + Digital cephalometric systems that were developed in 1970s-1980s used 'Dise Operating Systems' (DOS) , later it was upgraded . Digital Cephalometrics Computerised Cephalometrics Charge Coupled Device (CCD) or - Complemenrary metaloxide semiconductor (CMOS) apc Le Digital radiography (dR) omputed radiography (Cephalometric softwares Marktud by ator ‘Developed by C30 Chandigarh and CDER; AiliMS, New Det inca, ese ro fan veut een i aren z ror Fawn Ott, Sebo ik ee Aaa he atins Ss pCR ROSEN caDRaoOT Coat al aan OTNOTRCE ‘ort Te Ta a ‘saan Chea Cori ON seh Friinoope: Gore, Ano US mat i Ft onesie care A a a a ar i ci a era eS a meron? ——=SS”S”S*S”SCANAARCAUAC Ronee nc BA saree ha Ci i Big Co TA Sanco “Glace Software, mela ay ey Teor id abl Ty at ALS a Ge = GC eer aoa, New YO UA ae ie Corpo, Senda, apn3D Skeletal imaging -CT & CBCT ‘The first CT seanner was invented by Sir Godfrey N.Hounsfield in 1967. Xray tube & detector sean the skull image slice by slice of same thickness in axial direction from head to neck & each slice is stacked over one another in an orderly manner will give us the 3D image of the skull. cect: Type of beam Cone shaped Sean time Rapid scan time (10-703) Dose Range 51073 Sv Soft tissue Poor soft isu contrast mn fan shaped ‘More scan time, it takes some minutes tr a can to-compiete ange mandible 761-3324 Sr; mala 04-1202 Si Inletor 2s compare! to cect thas bone and sot ‘tue windows, makings wef lor determining ‘yerlous soft tissue details To detect impacted teeth and oral abnormalities Airway & Facial analysis Assessment of alveolar bone height & volume TMJ morphology Lateral and frontal Ceph views Skeletal views & 3D review of dentition3D cephalometric analysis * The first 3D cephalometric analysis was introduced by parket al. in 2006 Software tools for 3D evaluation Mimics (Materialize Co., Belgium) Dolphin (Dolphin Imaging Systems) AMIM (Mercury Computer Sys.Germany) Vitrea (Vital Images Inc..Plymouth, MN) Maxilim (Medicim, Sint-Nikaas, Belgium) ‘Anatomage (San lose, CA) S.no._30 analysis Benen heel etal GO Acre) Facronata G ‘ayome We ro] Gina Year 2005 2008 210 73 pore W6 Objective “To propor cephaiometnc analysis on vRUMNTC image baved en 20 landmarks “Anal thal coneat be pevforned on 2D radogrshs To compare he Tepont smetbod using 30 images andthe 20 Steines Lythos Ormco Corporation CS 3500, C tream ~ . PlanScan marketed by Planmeca 1,Ortho Insight 3D (Motion ViewSoftware) 2. R series, 3 Shape (Denmark) 3. Maestro 3D (ACE Solutions, ltaly)Non radiation methods Acoustic reflection MRI Radiation methods Fluoroscopy CT CBCTThe Hitachi MercuRay(Japan) has a stationary mode of a 10 sec recording, which can evaluate real time movement of oral & pharyngeal region, & proves to be useful in evaluating amount of the airway changes in mid sagittal yiew of an awake subject while sitting upright . Clinical implication of volumetric airway analysis * Mandibular advancement in skeketal base IT malocelusion * Rapid maxillary expansion & maxillary protraction * Orthognathic surgery + Extraction therapy & cffecys on airwayThe 3D triad in orthodontics Craniofacial Skeleton ae Face Scanner Intraoral Scanner + When these 3D technologies are combined using 3D software pearmees: 2D vival pipsdonsef sical plansiGkan te Fe Sid performed digitally. The integrated approach using these 3D data not only provides a smooth digital workflow in orthodontics but 4 may also offer reduced errors related to materials, appliance os Dentition fabrication and operator skillsRecent advances in AppliancesCustomized Appliances * Orthodontic appliances that are custom made to fit each individual patient’s teeth, and designed to move teeth from their initial malocclusion to a pre-determined outcome. * Invisalign, first introduced by Align Technology, Ine (USA) in 1997, is a technique that uses a series of customized transparent, removable aligners, which are designed and created using advanced computer technology, to orthodontically straighten teethSuresmile® system SureSmile, a product of OraMetrix (Richardson, TX, USA), is an orthodontic digital system that uses an optical intraoral scanner to acquire a 3D digital model of tecth and brackets. Customized arch wires are robotically formed to incorporate all necessary bends to exert forces and moments to achieve the desired position of teeth. Custom wires are used in non custom brackets to achieve an individualized treatment outcome.Incognito™ system - fully customized lingual bracket system. + Laboratory or digital set up is used to predetermine the desired positions of teeth. All lingual brackets are individually designed to closely adapt to lingual anatomy of all tecth. * Custom arch wires are robotically formed to incorporate all necessary bends to exert forces. and moments to achieve the desired position of teeth, ©) INGegnitoOrmco®’s Insignia™ - One of the most comprehensive CAD/CAM orthodontic appliances on the market, which was available in standard and self-ligating applications with optional use of esthetic ceramic brackets The organization offers patient-specific brackets, indirect-bonding transfer jigs, and custom archwires. The custom archwires are made by a printing robot that uses the system provided to trace and bend the wire accordingly, the rebot is very accurate and has a very small error margiMotoman up6 (LAMDA) Lingual archwire manufacturing and design aidBio MEMS/NEMS for Orthodontic Tooth Movement & Maxillary Expansion + Concept - Animal experiments indicated that when 15-20 wA of low direct current (DC) was applied to the alveolar bone to modifying the bioclectric potential osteoblasts and PDL cells, there is increased concentrations of the second messengers, cAMP and cGMP, leads to accelerated bone remodeling. Nanorobotics- Futuristic Approach * Nanorobotics are self-sufficient machines which are functional at the nanoscale, * Nanorobots with specific motility mechanisms would navigate through periodontium to remodel it directly ’ allowing. accelerated orthodontic tooth movement, 2rintin: + A three-dimensional (3-D) ptinting is also known as additive manufacturing or desktop fabrication. It is a process of making 3-D solid objects from a digital file. MATERIALS USED TO PRIS D OBJECTS Website with 3-D t ware Which database: loaded for free + 3-D Marvels 1. Google SketchUp *3-D Via+GrabCAD || 2, Tinkeread. * Google 3-D Warehouse || 3. Blender ng sof The kno materials Clear Bio-compatible (MED610) Vero Dent Plus (MED690) Vero Glaze (MED620) ee PolyJet dePIEZOCISION Dibard and colleagues have developed a minimally invasive technique that combines piezoelectric incisions and microincisions with selective tunneling that helps to produce hard and soft tissue grafting The new approach has led to reduced orthodontic treatment time, minimal postoperation discomfort, great patient acceptance, and enhanced or stronger periodontium. Histochemical studies have shown that piezocision is less invasive and less traumatic than corticotomy procedures, and bone can regenerate in up to 8 weeks. However, one problem associated with it is that it can create gingival defect.Ideal Mini-Implant Surface Using Nanoparticles + Currently, TADs are manufactured with smooth titanium surfaces because Complete osseointegration is a disadvantage that complicates their removal. see Lack of osseointegration is also one of the factors for the failure of TADs. * Biocompatible coatings like Titanium nanotubes are studied to evaluate if the nanotubular layer can enhance initial osseointegration and can serve as an interfacial layer between the newly formed bone and the TAD. Nanostenciled RGD(Arg-Gly-Asp)-gold patterns * To Improve the Primary Stability of TADs | Tricalcium phosphate (TCP) nanocoating Ultrafine grain-sized titanium (UFG Ti)Recent advances in BioengineeringOrthodontics in the year 2047 Genetically driven treatment plans Havens, B. Wadhwa, S. and Nanda, R.: J. Clin. Orthod, 41:549-556, 2007 Gene therapy for sutural growth disturbances: + Mutations in FGFR2 have been linked to several human craniosynostosis disorders, including Apert, & Crouzon syndromes. + Incases of craniosynostosis involving mutations in FGFR2, temporarily blocking FGFR2 signaling in the preosteoblasts within the sutural mesenchyme or providing. a different anti proliferation signal to these cells would allow normal sutural growth without surgical intervention.Gene therapy to enhance condylar growth using rAAV-VEGF Objective: To test the hypothesis that the introduction of specific vascular growth inducing genes would favorably affect mandibular condyle growth in rats over a limited experimental period Result: Enhancement of mandibular condyle growth occurred in backward and upward direction in VEGF group rather than control group. Local RANKL gene transfer to the periodontal tissue accelerates orthodontic tooth movement Kanzaki.H et al Gene Therapy 2006 Result — It was demonstrated that transfer of the RANKL gene to the periodontal-tissue ,activate osteoclastogenesis and accelerated the amount of experimental Toot movement. Local RANKL gene transfer might be a useful tool not only for shortening orthodontic treatment, but also for moving ankylosed teeth where teeth, fuse to the surrounding bone .Conclusion There have been many technological advances in orthodontics that have improved diagnosis, treatment planning, treatment precision, and treatment efficiency. However, none of these advances are a substitute for sound diagnosis, and clinical judgment, A high-tech customized orthodontic appliance that is capable of achieving excellent results with high precision will still result in a bad outcome if the diagnosis and treatment plan are not well thought out.References Orthodontics, current principles and techniques by Graber & Vanarsdall -6th edition Contemporary orthodontics by William Proffit- Sth edition Up in the Air;Orthodontic technology unplugged! 2017 APOS Trends in Orthodontics Smart bracket for multidimensional force and moment measurement.J Dent Res 86(1):73-78 The DigiGraph Work Station, Part 2: Clinical Management JCO 1990 Shetty NJ, Swati P, David K. Nanorobots: Future in dentistry.Saudi Dent J. 2013; 25(2) Orthodontics — Diagnosis and mangement of malocclusion and dentofacial abnormalities — Om Prakash Kharbanda — 3" edition