Micro-osteoperforations, VPro vibration device, and aligner therapy can accelerate orthodontic tooth movement.

In today’s post–COVID-19 office environment, both dentists and patients have had to adjust their lives with regard to how they dispense and receive dental care. In orthodontics, some aspects remain the same as patients are still seeking quality care, but now they want it more quickly and with fewer office visits. Like many of my colleagues, I have been searching for technologies and materials that will help me meet that patient demand without sacrificing quality of care. It’s especially enticing when these new approaches can even improve patient outcomes.

In addition to happier patients and greater clinical predictability in my cases, my bottom line is also reaping the benefits. Fewer appointments for one patient translate to more available spots for new or returning patients. This is important for busy practices and those that are trying to catch up by scheduling patients who have not been able to visit due to the COVID-19 shutdown. Now more than ever, we rely on technologies that can help us accomplish these things.

When patients desire a shorter orthodontic experience, or anatomical issues delay tooth movement longer than is considered normal or productive, the in-office procedure known as micro-osteoperforation (MOPs) can accelerate the rate of orthodontic tooth movement by up to 62%.¹ With a small perforation, or dimple as I call it, near the difficult tooth movement, MOPs stimulate the maximum biological response¹ while remaining microinvasive and palatable to the patient. Our other option for shorter treatments and increased predictability is high-frequency vibration (HFV), our at-home treatment with VPro in which patients use the VPro device for just five minutes per day. This therapy has also been shown to reduce treatment time by up to 64%.²

In my practice, I’ve found that these two therapies combined with aligner therapy reduce treatment discomfort, increase case predictability, optimize aligner seating, and reduce the need for additional refinement aligners. Patient comfort is key to a good treatment experience and often helps with compliance and engagement in the treatment. Five minutes of “soft pulsation” per day has been shown to reduce orthodontic discomfort by releasing the pain receptors that reduce inflammatory pressure.

My patient’s story began at the temporomandibular disorders (TMD) specialist’s office. At age 16, she was evaluated for headaches and jaw pain. She presented with bilateral coronoid pain, pain when chewing that preceded decreased range of motion on opening, and intermittent jaw locking. She had occasional jaw clicking and popping. She also suffered from weekly frontal headaches. The patient wore braces from ages 11–14, during which time she suffered with TMD pain. She had no history of headaches, jaw pain, or any TMD symptoms prior to wearing braces. Generally, her muscle groups exhibited moderate to severe tenderness upon palpation, and imaging revealed posterior displacement of both condyles.

Figure 1: Patient is struggling and uncomfortable — **Figure 1:** Patient is struggling and uncomfortable

She received a diagnosis of tension-type headache and anterior disc displacement with intermittent locking of the right and left temporomandibular joints. Orthopedic appliances were delivered to establish a better condyle-disc relationship and reduce the TMD-related symptoms. At that point, the patient was referred to our office for expansive orthopedic and orthodontic techniques.The patient presented to our office for initial evaluation and consultation at age 19. We collected a full set of records and performed a comprehensive clinical examination to develop a diagnosis and treatment plan. The face photograph alone showed us facial asymmetry, compensating posture, and someone who was uncomfortable and struggling (figure 1). The

Figure 2: Patient presents with narrow deficient smile and open buccal corridors — **Figure 2:** Patient presents with narrow deficient smile and open buccal corridors

smile photo showed a narrow, deficient smile with open buccal corridors (figure 2). The patient had a dental diagnosis of a Class I crowded malocclusion, which had an underlying cause of maxillary underdevelopment (figure 3). The patient had an improper arch form, which we described as an omega-shaped arch form (figure 4). She also had an improper arch width, and we assessed this by taking a transverse measurement between the upper first molars. She measured 27 mm, which was very narrow considering that adults without crowding measure 35–39 mm. Her narrow maxilla had a corresponding vaulted palate that

Figure 3: Patient diagnosis: Class I crowded malocclusion caused by maxillary underdevelopment — **Figure 3:** Patient diagnosis: Class I crowded malocclusion caused by maxillary underdevelopment

was clearly visible (figure 4). The patient had improper buccolingual inclination as most of the posterior teeth had excess lingual inclination. These three criteria accounted for a reduction in available tongue space, which delivered posterior displacement of the tongue and could have a negative effect on breathing and sleeping.

Figure 4: Patient presents with improper arch width: 27 mm transverse measurement (TM) — **Figure 4:** Patient presents with improper arch width: 27 mm transverse measurement (TM)

The Marchesan Lingual Frenum Protocol was performed to assess the level of tongue restriction. The patient scored five points out of a possible eight, indicating a moderate level of tongue restriction (figure 5). All of this added up to a diagnosis of maxillary deficiency, which had an adverse effect on the position of the mandible. The patient’s narrow, underdeveloped maxilla trapped her mandible in a retruded position upon closure, as evidenced by the posterior displacement of both condyles. She also had a tooth-size discrepancy in the upper arch, with tooth no. 7 being undersized and no. 10 a peg lateral.

Figure 5: Patient displays a moderate tongue-tie, scoring 5 on the Marchesan Frenum Protocol — **Figure 5:** Patient displays a moderate tongue-tie, scoring 5 on the Marchesan Frenum Protocol

All this diagnostic information was taken into consideration during the consultation process. Since the patient had foundation and tooth alignment issues, she would benefit from a treatment plan that addressed both issues. First, an upper removable expansion appliance offered a great opportunity to develop the maxilla. Second, clear aligners offered an excellent opportunity to align and coordinate all the teeth into a healthy occlusion. The patient would also benefit from a lingual frenum revision, which would be done with appropriate orofacial myofunctional therapy. Lastly, a vibration device, the VPro from Propel Orthodontics, was introduced and offered three key benefits:

An opportunity for better tracking
Improved patient experience by causing less discomfort
Shortened duration of treatment time with fewer office visits

Figure 6: Patient achieves significant maxillary growth in eight months with the use of accelerated orthodontics (VPro+ device) — **Figure 6:** Patient achieves significant maxillary growth in eight months with the use of accelerated orthodontics (VPro+ device)

The patient chose this treatment plan after a full discussion of all options, including the risks and benefits of each. At that point, a digital scan was taken and sent to Ohlendorf Appliance Laboratory with instructions to fabricate an upper removable expansion appliance.

A few weeks later, this appliance was delivered with instructions for wear time, cleaning, and advancing the screw mechanism. A VPro vibration device was also delivered with instructions to use it five minutes per day.

Within two weeks, the patient’s original symptoms began to decrease. With appropriate wear cycles and removal time of the expansion appliance, she achieved significant maxillary growth in just over eight months (figure 6). Now the patient had a transverse measurement of 34 mm between the upper first molars, which represents 7 mm of maxillary development, including a change in the palatal vault anatomy and a reduction in vault height (figure 7). The maxillary development released the mandible from its trapped position, which improved the relationship of the occlusion, condyle, disc, and musculature. As a result, she no

Figure 7: Patient achieves 7 mm of development resulting in a 34 mm TM and changes in palatal vault anatomy — **Figure 7:** Patient achieves 7 mm of development resulting in a 34 mm TM and changes in palatal vault anatomy

longer had weekly headaches, clicking or popping, or any tenderness in the musculature.

At that point, the foundation was developed, the patient was asymptomatic, and she was ready to transition to clear aligners. A digital scan was taken, and a clear aligner case was developed using an expansive technique to continue development of both arches. The patient did appropriate orofacial myofunctional therapy as well as the lingual frenum revision. She continued to use the VPro device for five minutes every day while wearing her aligners to ensure proper tracking and reduced discomfort. Clear aligners were used for 12 months and added another 3 mm of development to the maxillary arch.

Figure 8: Patient after palatal expansion and clear aligner therapy. Achieves 10 mm of expansion, which equals 37 mm of TM. — **Figure 8:** Patient after palatal expansion and clear aligner therapy. Achieves 10 mm of expansion, which equals 37 mm of TM.

The transverse measurement was now 37 mm at the end of treatment. This represented a total of 10 mm of maxillary expansion with a remodeled palatal vault (figure 8). The clear aligners also delivered full alignment of the teeth and a healthy, protective occlusion (figure 9). The tongue had an increased amount of oral cavity volume (figure 10). The tongue-tie had also been released via a lingual frenectomy and the tongue trained via orofacial myofunctional therapy to live high and forward in the palate. This can have a

Figure 9: Clear aligners deliver full alignment and proper occlusion — **Figure 9:** Clear aligners deliver full alignment and proper occlusion

positive effect on the patient’s breathing and sleeping. Teeth nos. 7 and 10 were restored to a proportional size with composite, and a set of clear retainers was delivered. She will wear the retainers every night forever and replace them as needed. At the completion of treatment, the patient had achieved maxillary development, tooth alignment with occlusal coordination, and

Figure 10: The tongue has an increased amount of oral cavity volume — **Figure 10:** The tongue has an increased amount of oral cavity volume

neuromuscular harmony. She had a healthy, stable, functional, and comfortable occlusion as well as a beautiful smile. The patient was now completely asymptomatic and thriving at the end of treatment (figure 11). Fast-forward four years, and she remains completely free of headaches and TMD symptoms. She has continued to wear her

Figure 11: Patient is completely asymptomatic and thriving, and has a beautiful, healthy smile. — **Figure 11:** Patient is completely asymptomatic and thriving, and has a beautiful, healthy smile.

retainers every night during this time, and she is able to wear the VPro in retention to ensure the retainer is seating properly and avoiding relapse.

This is just one of many patients who have benefited from having techniques from Propel Orthodontics incorporated into their treatment. The opportunity is significant whether we utilize VPro HFV or MOPs. Both techniques offer a reduction of treatment time and treatment visits, better tracking, and less discomfort at an affordable price. All of this combines to make a more profitable, predictable, and comfortable orthodontic treatment that improves both the health of the patient and the practice.

References

Alikhani M, Raptis M, Zoldan B, et al. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013;144(5):639-648. doi:10.1016/j.ajodo.2013.06.017
Alansari S, Atique MI, Gomez JP, et al. The effects of brief daily vibration on clear aligner orthodontic treatment. J World Fed Orthod. 2019;7(4):134-140, doi:10.1016/j.ejwf.2018.10.002

BEN MIRAGLIA, DDS, a graduate of the State University of New York at Buffalo School of Dental Medicine, has practiced general dentistry for 26 years in Mt. Kisco, New York, including 16 years of interceptive orthodontics with a focus on early childhood growth and development. An international lecturer, he is on the Align Technology faculty, the American Academy of Physiological Medicine and Dentistry Board of Directors, the Northern Westchester Hospital President’s Council, and is vice president of clinical affairs for Airway Health Solutions. To learn more about expansive orthodontics, contact Dr. Miraglia at [email protected] or visit airwayhealthsolutions.com.