Innovative virtual set-up to evaluate arch form effects

Article (PDF Available)inCzasopismo stomatologiczne 66(5):685-692 · September 2013with 449 Reads
DOI: 10.5604/00114553.1065053
Abstract
Introduction. An innovative virtual set-up is proposed to evaluate individual arch form effects on dental crown and root position during alignment. Materials and methods. Angle Class I and skeletal Class I (ANB = 2°) of the patient are taken. A superimposition of the scanned model and the cone beam (CBCT) image is carried out to obtain dental crown and root anatomy. Virtual alignment is obtained following individual arch form and full expression of Roth prescription bracket. Final crown and root position is visualized in relation to the original dental arch. Conclusion. In the era of CBCT, a great deal of attention has to be given not only to final crown position, but also to final root position as regards cortical limits. It has become important to individualize not only the arch form, but also the bracket, to obtain better results in stability and dental health.
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685
ORIGINAL ARTICLE
J Stoma 2013; 66, 5: 685-692 © 2013 Polish Dental Society
Streszczenie
Wstęp. Praca ma na celu przedstawienie innowacyjnej
metody wirtualnego set-up’u dla oceny efektów
działania łuków ortodontycznych o różnych kształtach
na pozycję koron i korzeni zębów podczas fazy
szeregowania. Materiał i metody. Do badania
wybrano pacjenta prezentującego I klasę Angle’a
i I klasę szkieletową (kąt ANB=2°). W celu uzyskania
dokładnej anatomii zarówno koron, jak i korzeni
zębów dokonano superimpozycji (nałożenia) skanu
3D modeli oraz obrazu komputerowej tomograi
stożkowej (CBCT) pacjenta. Zostało przeprowadzone
wirtualne szeregowanie zębów z uwzględnieniem
indywidualnego kształtu łuku oraz pełnej ekspresji
preskrypcji Rotha zamków ortodontycznych.
Uzyskana nowa pozycja koron i korzeni zębów została
przedstawiona w odniesieniu do oryginalnego kształtu
łuku. Podsumowanie. W dobie obrazowania metodą
tomograi stożkowej należy zwrócić szczególną
uwagę nie tylko na uzyskaną leczeniem pozycję koron,
ale szczególnie korzeni zębów z uwzględnieniem
ograniczeń budowy blaszki kostnej kortykalnej. Istotne
staje się, aby indywidualnie dobierać nie tylko łuki, ale
również zamki ortodontyczne dla osiągnięcia lepszych,
bardziej stabilnych wyników leczenia.
Innovative virtual set-up to evaluate arch form effects
Innowacyjna metoda wirtualnego set-up’u dla oceny efektów działania
różnych kształtów łuków ortodontycznych
Gianluca Luini1, Anna Hille2, Piero Antonio Zecca3, Aldo Macchi4,
Bartłomiej W. Loster2, Alberto Caprioglio3
1 Private Practice, Sumirago, Varese, Italy
 PrywatnaPraktyka,Sumirago,Warese,Włochy
Head: lek. dent. G. Luini
2 Katedra Ortodoncji, Instytut Stomatologii, Wydział Lekarski, UJCM, Krakw, Polska
DepartmentofOrthodontics,DentalInstitute,MedicalFaculty,JagiellonianUniversity,MedicalCollege,Cracow,Poland
 Head:drhab.B.W. Loster,prof.UJ
3 Department of Orthodontics, University of Insubria, Varese, Italy
 KatedraOrtodoncji,UniwesytetInsurbia,Varese,Włochy
Head: prof. A.C. Porisini
4 Department of Dental Material, University of Insubria, Varese, Italy
 KatedraMateriałówStomatologicznych,UniwesytetInsurbia,Varese,Włochy
Head: prof. A.C. Porisini
Summary
Introduction. An innovative virtual set-up is proposed
to evaluate individual arch form effects on dental
crown and root position during alignment. Materials
and methods. Angle Class I and skeletal Class I
(ANB = 2°) of the patient are taken. A superimposition
of the scanned model and the cone beam (CBCT) image
is carried out to obtain dental crown and root anatomy.
Virtual alignment is obtained following individual
arch form and full expression of Roth prescription
bracket. Final crown and root position is visualized
in relation to the original dental arch. Conclusion. In
the era of CBCT, a great deal of attention has to be
given not only to nal crown position, but also to nal
root position as regards cortical limits. It has become
important to individualize not only the arch form, but
also the bracket, to obtain better results in stability
and dental health.
KEYWORDS:
dental arch, root position, arch form, superimposition, cone
beam computed tomography
HASŁA INDEKSOWE:
łuk zębowy, pozycja korzeni, kształt łuku, superimpozycja, kom-
puterowa tomografia stożkowa
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J Stoma 2013; 66, 5 Luini G., Hille A., Zecca P.A., Macchi A., Loster B.W., Caprioglio A.
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Introduction
The purposes of orthodontic treatment are to
reach not only an optimal occlusal, functional
and aesthetic result, but also a stable result over
time.1-3
The post-treatment stability has always
represented a real challenge for specialists since
some studies reveal that many cases, although
treated respecting the Andrews six keys of
occlusion,4 showed great relapse tendency.
According to Little’s studies, after retention period,
only 30% of the cases maintained a satisfactory
aligment5 while 20% of the patients showed high
tertiary relapse.6
There are several investigations which aimed at
discovering factors that could inuence orthodontic
treatment stability: dental class reached, retention
period, age at the start of treatment, gender.6
Moreover, original irregularity index,7,8 arch depth
and arch width are important characteristics that
inuence post-treatment stability.9,10 In particular,
many studies have shown that alterations of
the intercanine and intermolar distance during
orthodontic treatment are related to a greater
relapse rate,11-13 since dental arch tends to return
to its original form. So, maintaining the original
arch form seems to be the key for more stable
orthodontic treatment.11-15
Many works have also pointed out a great
variability of the human dental arch form among
individuals,16 for skeletal class,17 age,18 gender
and ethnicity.19 Some authors have proposed
mathematical functions to describe universally
various arch forms,20-22 others have simply
catalogued them,16,23 others have described
methods to create individual arch choosing
dental24 or dento-alveolar references.25
Therefore, it is evident that treating all patients
with commercially preformed arches may not be
the optimal solution, especially if the main aim is
to reach the most stable results: an individual arch
wire is needed. But what about brackets? Are we
sure our patients do not need individual tip and
torque information?
This paper proposes an innovative 3D set-up
aimed at estimating the effects of a virtual dental
alignment, obtained with an individual arch wire
Wstęp
Celem leczenia ortodontycznego jest osiągnię-
cie optymalnego rezultatu nie tylko z punktu wi-
dzenia okluzji, funkcji i estetyki, ale również re-
zultatu, który będzie stabilny w czasie.1-3
Stabilność po leczeniu ortodontycznym stanowi
wyzwanie dla klinicystów. Szereg badań odnoto-
wuje wysoki odsetek nawrotów, nawet w przypad-
kach, w których uzyskano okluzję zgodną z sze-
ścioma kluczami Adrewsa.4 Zgodnie z badaniami
Little’a, po okresie retencji tylko 30% przypad-
ków utrzymało zadowalające uszeregowanie -
bów,5 a u 20% leczonych doszło do znacznego
nawrotu wady.6
Istnieje szereg doniesień na temat czynników
wpływających na stabilność po leczeniu ortodon-
tycznym: osiągnięta klasa zębowa, okres retencji,
wiek pacjenta w momencie rozpoczęcia leczenia,
płeć.6 Również mierzone wartości wyjściowe, ta-
kie jak: indeks stłoczeń,7,8 długość i szerokość łuku
wpływają na stabilność po leczeniu.9,10 W szcze-
gólności, jak wykazało wiele badań, zmiany doty-
czące odległości międzykłowej i międzytrzonow-
cowej są powiązane z większym ryzykiem nawro-
tu,11-13 ponieważ łuk zębowy wykazuje tenden-
cję do powrotu do swojego wyjściowego kształtu.
A zatem, zachowanie indywidualnego kształtu łuku
wydaje być się kluczem do osiągnięcia stabilnych
rezultatów leczenia ortodontycznego.11-15
Wiele opracowań wskazuje na dużą osobniczą
zmienność kształtów łuków zębowych,16 zależ-
ną również od klasy szkieletowej,17 wieku,18 płci
i rasy.19 Niektórzy autorzy proponują funkcje ma-
tematyczne do uniwersalnego opisania różnorod-
nych kształtów łuków,20-22 inni je pogrupowa-
li,16,23 lub opisali metody indywidualnego plano-
wania kształtu łuku w oparciu na kryteriach zębo-
wych24 lub zębowo-wyrostkowych.25
Po uwzględnieniu powyższych uwarunko-
wań, oczywiste staje się, że leczenie pacjentów
z wykorzystaniem prefabrykowanych łuków or-
todontycznych może nie być optymalnym roz-
wiązaniem. Biorąc pod uwagę zwłaszcza stabil-
ność osiągniętego wyniku leczenia, potrzebne jest
zachowanie indywidualnego kształtu łuku. A co
z zamkami? Czy nie potrzeba również zindywidu-
alizowanych wartości nachylenia i torku?
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and with the complete expression of virtual bracket
information of Roth prescription. Final crown and
root position have been investigated.
Materials and method
A 14-year-old male patient, who required
Cone Beam CT to evaluate third lower molars,
was selected. The patient was taken CBCT
(ICat, Imaging Sciences International, Hateld,
Hertfordshire, United Kingdom; slices of 0.300
mm) wearing a bite, with ve radiopaque references;
afterwards, the plaster casts of the patient were
scanned (NextEngine HQ, NextEngine Inc, Santa
Monica, California, USA; laser error of 0.01 mm)
with the same bite used for CBCT (Fig. 1a-b).
The references consisted of 20% barium resin, to
be easily recognizable from CBCT images, and
they had a specic anatomic form, to be easily
recognized by the laser scanner (Fig. 2).
With the aim of improving a method proposed
by Macchi et al.,26 with the aid of Mimics software
(Mimics 10, Materialize Group, Leuven, Belgium)
it was possible to superimpose on the radiopaque
references the scanned plaster casts on the CBCT
image (Fig. 3a); then, only the lower dental arch
of the patient was superimposed on the CBCT
image (Fig. 3b). Scanned dental crowns were cut
out from the lower dental arch and then fused
to dental roots obtained from the CBCT image
(Fig. 3c). With Rhinoceros software (Rhinoceros
Celem tej pracy jest przedstawienie innowa-
cyjnej metody trójwymiarowego set-up’u dla
oceny efektów wirtualnego szeregowania zębów
osiągniętego z wykorzystaniem indywidualne-
go kształtu łuku oraz pełnej ekspresji preskryp-
cji Rotha wirtualnych zamków ortodontycznych.
Oceniano uzyskaną pozycję koron i korzeni -
bów.
Materiał i metody
Do badania zakwalikowano 14-letniego pa-
cjenta, u którego była konieczność wykonania
komputerowej tomograi stożkowej dla oceny
położenia trzecich zębów trzonowych. Badanie
CBCT (ICat, Imaging Sciences International,
Hateld, Hertfordshire, United Kindom; grubość
warstwy 0,300 mm) wykonano z założoną szyną
zaopatrzoną w radiopakerowe punkty referencyj-
nie. W następnym etapie dokonano skanu gipso-
wych modeli diagnostycznych (NextEngine HQ,
NextEngine Inc, Santa Monica, California, USA;
błąd laseru 0,01 mm) z wykorzystaniem tej samej
szyny (Fig. 1a-b). Punkty referencyjne składały
się w 20% z żywicy baru, co pozwalało na łatwą
identykację na obrazie CBCT i miały specycz-
ny kształt dla łatwiejszego rozpoznania przez ska-
ner laserowy (Fig. 2).
W celu udoskonalenia metody zaproponowa-
nej przez Macchi i wsp.,26 za pomocą oprogra-
mowania Mimics (Mimics 10, Materialize Group,
Fig. 2. An object that can be easily recognized by the laser scanner was
selected; then, it was converted in a 20% barium resin object, easily
recognizable by CBCT images; finally, five of them were attached to a
radiotransparent resin bite.
Do stworzenia punktów referencyjnych wybrano kształt łatwo rozpoznawal-
ny przez skaner, a następnie pokryto go 20% żywicą baru, dającą wyraźny
kontrast na obrazach CBCT. Pięć takich elementów zamocowano na szynie
przepuszczalnej dla promieni rentgenowskich.
Fig. 1. a – CBCT image of the patient wearing a bite with five radio-
paque references; b – laser scanner image of the plaster casts of the
patient with the same interposed bite.
a – obraz CBCT pacjenta z założoną szyną zaopatrzoną w pięć radiopake-
rowych punktów referencyjnych; b – obraz skanu laserowego gipsowych
modeli diagnostycznych pacjenta z założoną szyną.
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4 SR8, McNeel, North America, Seattle, USA)
it was possible to turn an individual arch wire
created for the patient into 3D (Fig. 4) and to create
virtual brackets for the lower arch according to
Roth prescription (Fig. 5). With Carrara software
(Carrara 8, Daz-3D, Draper, USA) it was possible
to apply a virtual bonding, attaching to each virtual
tooth its virtual bracket (Fig. 3d-e); then, a virtual
set-up was carried out (Fig. 6).
Leuven, Belgium) dokonano nałożenia obrazu
skanu modeli na obraz CBCT zgodnie z radiopa-
kerowymi punktami referencyjnymi (Fig. 3a). Do
dalszej części badania wykorzystano superimpo-
zycję samego dolnego łuku pacjenta (Fig. 3b).
Skan laserowy koron zębowych dolnego łuku zo-
stał wyodrębniony i połączony z obrazem CBCT
korzeni zębów (Fig. 3c). Za pomocą oprogramo-
wania Rhinoceros (Rhinoceros 4 SR8, McNeel,
North America, Seattle, USA) stworzono indywi-
dualne łuki ortodontyczne (Fig. 4) oraz wirtual-
ne zamki dla łuku dolnego zgodne z preskrypcją
Rotha (Fig. 5). Program Carrara (Carrara 8, Daz-
3D, Draper, USA) pozwolił na wirtualne przykle-
jenie zamków do powierzchni wirtualnych zębów
(Fig. 3d-e). Następnie przeprowadzono wirtualny
set-up (Fig. 6).
Fig. 3. a superimposition on CBCT image-laser scanner image; b
superimposition on CBCT image-scanned lower dental arch image;
c – anatomic crowns obtained from scanned lower dental arch image
fused with dental roots obtained from CBCT image d-e – virtual bracket
bonding.
a nałożenie obrazów CBCT i skanu modeli; b – nałożenie skanu łuku
dolnego na obraz CBCT; c – anatomia koron dolnego łuku zębowego uzy-
skana ze skanu połączona z obrazem CBCT korzeni zębów; d-e – wirtualnie
przyklejone zamki ortodontyczne.
Fig. 4. Individual arch form virtually 3D built.
Indywidualne kształty łuków ortodontycznych stworzone wirtualnie w 3D.
Fig. 5. Roth prescription brackets virtually 3D built.
Zamki ortodontyczne o preskrypcji Rotha stworzone wirtualnie w 3D.
Fig. 6. Result of the alignment obtained with the individual arch form.
Rezultat szeregowania przy zastosowaniu indywidualnego kształtu łuku.
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In order to verify dental crown and dental root
movements obtained with this virtual set-up, it was
necessary to superimpose the dental arch aligned
on the original dental arch of the patient. A new
method of superimposition was developed.
In accordance with the studies on dental
movements in the three planes of the space during
curve of lower arch levelling,27,28 they were taken
as reference points for the superimposition:
Aby ocenić zakres przemieszczeń koron i ko-
rzeni zębów uzyskanych w wyniku wirtualnego
set-up’u, konieczna jest superimpozycja uszere-
gowanego łuku zębowego na wyjściowy kształt
łuku pacjenta. Zaproponowano nową metodę su-
perimpozycji.
Zgodnie z badaniami przemieszczeń zębowych
w trzech płaszczyznach, jakie zachodzą podczas
wyrównywania krzywej dolnego łuku zębowe-
Fig. 7. a – the plane passing through the disto-vestibular cusps of the
second molars and the tips of the canines, on the original arch; b – the
plane passing through the disto-vestibular cusps of the second molars
and the tips of the canines, on the aligned arch; c – superimposition of
the original and aligned arches, on the vertical dimension.
a – płaszczyzna przechodząca przez dystalno-policzkowe guzki drugich zę-
bów trzonowych i guzki kłów w łuku przed szeregowaniem; b – płaszczyzna
przechodząca przez dystalno-policzkowe guzki drugich zębów trzonowych i
guzki kłów w łuku uszeregowanym; c – superimpozycja łuku wyjściowego i
uszeregowanego w płaszczyźnie pionowej.
Fig. 8. a – the dental midline point and the contact points of the first
and second molar, left and right, on the original arch; b – the dental
midline point and the contact points of the first and second molar, left
and right, on the aligned arch; c – superimposition of the original and
aligned arches, on the antero-posterior and transversal dimension.
a – punkt styczny pomiędzy zębami siecznymi przyśrodkowymi oraz punkty
styczne pomiędzy pierwszym a drugim zębem trzonowym po prawej i po
lewej stronie w łuku wyjściowym; b – punkt styczny pomiędzy zębami siecz-
nymi przyśrodkowymi oraz punkty styczne pomiędzy pierwszym a drugim
zębem trzonowym po prawej i po lewej stronie w łuku uszeregowanym;
c superimpozycja łuku wyjściowego i uszeregowanego w płaszczyźnie
przednio-tylnej i poprzecznej.
Fig. 9. Superimposition of the virtual alignment on the original dental
arch, with particular consideration for the alveolar bone: a – front view
b – occlusal view.
Superimpozycja wirtualnego szeregowania na wyjściowy kształt łuku ze
szczególnym uwzględnieniem kości wyrostka zębodołowego: a – widok z
przodu, b – widok od strony okluzji.
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on the vertical dimension, a plane passing
through the disto-vestibular cusps of the
second molars and the tips of the canines
(Fig. 7),
on the antero-posterior and transversal di-
mension, the dental midline point and the
contact points of the rst and second molar,
left and right (g 8).
In this way, it was possible to formulate
hypothesis on the effects of an alignment obtained
with the individual arch wire form and the above-
mentioned method of superimposition. It was
possible to study not only the nal crown position,
but also the nal root position with respect to the
alveolar bone (Fig. 9).
Discussion of results and conclusion
In the last 15 years, a growing interest in virtual
set-up has quickly developed. The innovation lay
in the possibility to determine digital nal results
so that expected results can be obtained, case per
case, and to simplify clinician’s practice.
For this reason, virtual set-ups have soon become
very popular. Unfortunatelly, this digital planning
still has imperfections. In fact, the most known
virtual set-ups (Invisalign, Ormco Insigna, Lingual
Care) are carried out moving only dental crowns:
they do not involve dental root movements.
So, how is it possible to obtain a nal stable
result if root positions are not investigated?
This virtual set-up is innovative inasmuch it
is possible to evaluate not only nally crown
position that depends on the chosen arch form,
but also the presumed nal root position and its
relation to alveolar bone that results from bracket
information.
In fact, in the era of CBCT, root position and
root health have gained more and more importance.
Since dental torques depend on skeletal divergency
and they are different from patient to patient,29 it
is not that foregone that brackets with standard
information are suitable for every patient.
This method of virtual set-up would enable
better design of an individual arch as well as
individual brackets that would have a better
performance with respect to alveolar bone limits.
Unfortunately, in this virtual study, it was not
go,27,28 do superimpozycji zostały wybrane nastę-
pujące linie referencyjne:
– w wymiarze pionowym – płaszczyzna prze-
chodząca przez dystalno-policzkowe guz-
ki drugich zębów trzonowych i guzki kłów
(Fig. 7),
w wymiarze przednio-tylnym i poprzecznym
– punkt styczny pomiędzy przyśrodkowymi
zębami siecznymi oraz punkty styczne po-
między pierwszym i drugim zębem trzono-
wym po prawej i po lewej stronie (Fig. 8).
Na tej podstawie możliwe było sformowa-
nie hipotezy dotyczącej efektów szeregowania
przy zastosowaniu indywidualnych kształtów łu-
ków i opisanej metody superimpozycji obrazów.
Możliwa była ocena nie tylko docelowej pozycji
koron, ale również korzeni zębów w relacji do ko-
ści wyrostka zębodołowego (Fig. 9).
Omówienie wyników i podsumowanie
W ciągu ostatnich 15 lat nieprzerwanie rozwija
się zainteresowanie metodami dokonywania wir-
tualnego set-up’u. Innowacja polega na możliwo-
ści cyfrowej wizualizacji spodziewanych rezulta-
tów, co ułatwi ich osiągnięcie we wszystkich przy-
padkach i uprości pracę kliniczną.
Z tych powodów metody wirtualnego set-up’u
stały się bardzo szybko popularne. Niestety nadal
nie jeszcze doskonałe. Większość najbardziej
znanych oprogramowań służących do wirtualne-
go set-up’u (Invisalign, Ormco Insigna, Lingual
Care) pozwala jedynie na przesuwanie koron zę-
bów bez uwzględnienia przemieszczeń korzeni.
A czy możliwe jest osiągnięcie stabilnego rezul-
tatu leczenia bez zaplanowania pozycji korzeni
zębów?
Zaprezentowana metoda wirtualnego set-up’u
pozwala na określenie nie tylko docelowej pozy-
cji koron, która zależy od dobranego kształtu łuku
ortodontycznego, ale również docelowej pozycji
korzeni i ich stosunku do kości wyrostka zębo-
dołowego, które wynikają z ustawień zawartych
w standardowych zamkach.
W dobie obrazowania metodą komputerowej to-
mograi stożkowej zwraca się coraz większą uwa-
gę na pozycję i zdrowie korzeni zębów. Ponieważ
tork zębów zależy od dywergencji szkieletowej
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Innovative virtual set-up to evaluate arch form effects J Stoma 2013; 66, 5
http://www.jstoma.com
691
possible to evaluate some important factors that
could inuence the alignment and the levelling of
curve of lower arch such as the muscular forces,
tongue and cheek forces, individual response to
treatment, bone remodelling, the game wire-slot.
Further investigations are planned to verify the
reliability of this new method.
i jest osobniczo zmienny,29 nie należy zakładać,
że standardowe zamki ortodontyczne są właściwe
dla wszystkich pacjentów.
Ta metoda wirtualnego set-up’u mogłaby po-
zwolić nie tylko na dobranie indywidualnego
kształtu łuku, ale również indywidualnie dobie-
ranych zamków, które lepiej będą działać w gra-
nicach wyznaczonych przez blaszkę kostną kor-
tykalną.
W ramach ograniczeń badania nie była możliwa
ocena innych ważnych czynników, które wpływa-
ją na szeregowanie zębów i spłaszczenie krzywej
dolnego łuku zębowego, takich jak siły mięśni, ję-
zyka i policzków, indywidualną odpowiedź na le-
czenie, przebudowę kości oraz grę łuku w slocie
zamka. Planowane są kolejne badania dla oceny
wiarygodności zaproponowanej metody.
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Address:DepartmentofOrthodontics,UniversityofInsubria,
Varese,Italy
Tel.: +4812 4245442
e-mail:alberto.caprioglio@uninsubria.it
Received:3rdAugust2013
Accepted:10thAugust2013
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