Arch Reformulation Therapy (“ART”): The Case Studies of Two Patients

Patient #1

Chief Concern:

This 22 year old male would like to have a smile where his two yellow front teeth don’t stand out.

Dental History:

As an eight year old, teeth #7, 8 were avulsed in a baseball accident and subsequently replanted by his dentist. Teeth #7, 8 were discolored and missing portions of their enamel, even though both had previously received appropriate dental treatment (composite restorations, whitening) on more than one occasion. As a 16 year old, he received approximately one year of orthodontic aligner therapy. While there may have been some benefits at one time from the orthodontics, none were present at age 22. Mild gingivitis and gingival recession were present, but no pockets probed beyond 3mm.

Recent treatment recommendation:

  • Traditional orthodontic retreatment
  • 2-4 full coverage ceramic restorations
  • 0-10 porcelain veneers

Treatment proposed, accepted and rendered:

  • Arch Reformulation Therapy (“ART”) with periodontal aligners
  • Manhattan Method for the teeth whitening of smiles whose teeth possess various shades
  • Direct composite restorations teeth #7, 8

Patient and General Background:

Prior to his initial visit, the most recent dental recommendations (e.g., traditional orthodontic retreatment, 2-4 full coverage ceramic restorations, 0-10 porcelain veneers) might have been influenced by the results of his prior dentistry (e.g., whitening, restorative, orthodontic aligner care) over the past dozen or so years which were either unsuccessful or lasted for a shorter time than the patient, his parents and doctor had hoped.

The patient presented four years after the conclusion of his orthodontic aligner therapy. As is common with those who’ve received orthodontic treatment, his dentition and occlusion were neither ideal nor stable. Kaan and Madlena’s comprehensive review which evaluated the longevity of orthodontic care noted that teeth showed signs of being repositioned to less desirable locations post-treatment 70%-90% of the time.[1]

That’s another way to state that orthodontic care is successful 10%-30% once active care has concluded (e.g., bracket debonding, last orthodontic aligner). If dental considerations were factored (e.g., periodontal health, TMD, impact upon direct and indirect restorations), the dental success rate would likely be well below that 10%-30% range. Although noted as consequences, not one study tabulated or tracked non-orthodontic dental problems.  The publication of that significant review might have been the impetus for the ADA Code Maintenance Committee to revise (unanimously, with one abstention) the CDT definition of comprehensive orthodontic treatment (D8070, D8080, D8090) at their February 2013 meeting. The essential phrase present for many years “Optimal care requires the long term consideration of patient’s needs and periodic re-evaluation” was deleted from the descriptor.[2]

Slutzkey and Levin pointed out that the breadth of this patient’s recession was common in his age group (18-22 years old). When they compared recipients of orthodontic therapy with non-recipients, the increased incidence of their gingival recession ranged from 500%-800%.[3]  That’s why it’s understandable for a clinician to conclude a patient might not be a candidate for orthodontic retreatment, be prone to orthodontic relapse and to factor the presence of his chronic malocclusion when attempting to maximize the longevity of the restorations.

In contrast to the multitude of articles which support the concept of endodontic retreatment[4][5], there aren’t any randomized controlled studies which purport a success rate for orthodontic retreatment. Yu concluded that there is an “urgent need” for those studies to identify the most effective method for managing relapse, because one does not presently exist.[6]

Obtaining a stable result after the repositioning of teeth is vital. The phrase orthodontic relapse is often inaccurately attributed to describe consequences from a patient whose orthodontic therapy failed to achieve a stable result. If a stable result is not achieved, then there’s nothing to relapse from. If a stable or soon to be stable result is not obtained, Sadowsky and Saklos concluded that no retention method could provide a lasting result.[7]  Littlewood and his co-authors were even more succinct when they stated “there is currently insufficient evidence on which to base the clinical practice of orthodontic retention.”[8]

Arch Reformulation Therapy:

ART is a dentally gentle protocol which uses periodontal aligners to modify the underlying osseous substructure and improve the health of the gingiva, which is one of the goals of treatment. Another goal is to improve the occlusion, teeth positions and axial inclinations which will help the oral cavity to maintain its stability and become more resistant to the accumulation of plaque and stain. The results from ART contrasts with those from orthodontic therapy, where Bollen’s systemic review determined periodontal improvement is not and should not be an expected outcome from comprehensive orthodontic treatment.[9]

Should one be fortunate and obtain a stable orthodontic result at the conclusion of care, a definitive protocol to maintain that excellent outcome does not presently exist. [10][11]

Patients who possess dental conditions which contraindicate their ability to receive traditional orthodontic or orthodontic aligner therapy exclusively (e.g., TMD, mobile teeth, primary teeth, teeth with poor crown root ratios, elective orthognathic therapy candidates, ankylosed teeth) possess traits which are indications to initiate ART.

ART designs and programs periodontal aligners, indistinguishable in appearance from orthodontic aligners, to achieve a greater range of and more predictable movements than can be accomplished with traditional non-surgical orthodontics, elective orthognathic surgical/implant-aided orthodontics, or orthodontic aligners.

ART has defined phases. The overwhelming majority of desired movements are accomplished during the active phase. Modest amounts of osseous reformulation continue during each of the passive phases.

Initial anterior view: Day 1

Month 8: conclusion of ART Active Phase
(Periodontal aligners)

2 years into Passive Phase (retainers)

3 years into Passive Phase

4 years into Passive Therapy

Four years after orthodontic aligners

Four years after periodontal aligners

Caption / comments:

The yellow line which bisects the maxillary central incisors shows the reduction of the midline asymmetry that was present at the onset, reduced at the end of active therapy and just about eliminated a couple of years into passive therapy.

The lavender arrows point to representative gingiva which became more healthful as the recession which was generalized stabilized or decreased.

The orange arrows point to teeth which responded positively to the Manhattan Method of teeth whitening.

 

Patient #2

Chief Concern:

This 25 year old woman would prefer to have dental treatment which does not include gingival graft surgeries or orthodontic treatment.

Dental History:

At age 12, she started four years of orthodontic therapy (palate expander, extraoral headgear, traditional orthodontics, etc.). Even though she was a conscientious and compliant patient, instability became rampant shortly after the completion of care. Her periodontal health was excellent prior to the orthodontic care. Gingival recession and root sensitivity started partway through her orthodontic treatment. Her gingival health continued to decline, increasing in breadth and severity throughout the remainder and after the conclusion of her orthodontics. Three years ago, at age 23, she had an epithelial and connective tissue graft in the mandibular anterior region. Her periodontist suggested additional grafting procedures to protect her roots and diminish their thermal sensitivity.

Recent treatment recommendation:

  • Traditional orthodontic retreatment
  • four gingival grafting surgeries
  • 0-6 porcelain veneers

Treatment proposed, accepted and rendered:

  • ART with periodontal aligners

Patient and General Background:

The patient presented ten years after the conclusion of her traditional orthodontic therapy and three years after her gingival grafting (recipient and donor site) surgeries. As is common with those who’ve received orthodontic treatment, her periodontal health and occlusion were neither ideal nor stable.

Prior to her initial visit, the most recent dental recommendations (e.g., traditional orthodontic retreatment, 0-6 porcelain veneers, four gingival grafting procedures) left her highly anxious.

It was a challenge for her to have confidence in the near-identical treatment plan proposed by the same orthodontist who rendered her prior unsuccessful care. She wanted to consider every option which would allow her to avoid the pain and discomfort which lingered for months following her prior gingival grafting surgery.

While many articles detail the issues which face patients and clinicians upon the cessation of orthodontic therapy (e.g., teeth which lack stability, periodontal manifestations which weren’t present at the onset, compromised occlusion, TMD), there has yet to be a single randomized controlled study which points to consistent improvement to the gingival health.[12] The continuing improvement of the periodontal health during and after the conclusion of ART is a unique and warmly appreciated benefit by patients and clinicians.

 

Patient #2

Initial anterior view: Day 1

Month 7+: conclusion of ART
[Active Phase – periodontal aligners]

1 year into Passive Phase (retainers)

3 years into Passive Phase

4 years into Passive Therapy

5 years into Passive Therapy

10 years post-traditional orthodontic care
3 years after gingival grafting surgery

5 years post-ART, 16 years post-orthodontics
9 years after gingival grafting surgery

Conclusion:

The positive dental results (improved periodontal health and occlusal stability) in these two individuals are representative of what one should expect after ART. These patients prior orthodontic experience – one with traditional orthodontics, one with orthodontic aligners; did not yield stable results. The instability negatively impacted their periodontal health and occlusion. Based on findings by orthodontic researchers, their results would not be considered atypical or unexpected.

ART and orthodontic therapy have different goals. ART merits classification as a long term dental therapy. While gingival health is one of the two criteria which measures the success of ART, periodontal health is not one of the eight criteria used by the American Board of Orthodontics Grading System for Dental Casts and Panoramic Radiographs to measure the success of an orthodontic therapy.[13][14][15][16][17]

ART can treat a number of patients non-surgically which would otherwise require elective orthognathic surgery in conjunction with pre- and post-surgery orthodontic treatment.

Mobile and ankylosed teeth are often indications to initiate ART. Teeth with those conditions are usually excluded from or serve to contraindicate orthodontics from consideration within a treatment plan.

ART has a definitive protocol to conclude therapy. Orthodontic researchers confirm a definitive “best way” to conclude orthodontic therapy does not exist and there is no evidence that one ever has.

The ART retention methodology is unambiguous and integrated within the protocol. Not only is there no proven retention methodology for comprehensive orthodontics, the selection of the retention option is often made by the patient, not the clinician.

The word most frequently used by patients to describe their mouths at the conclusion of ART is “stronger.”

The ADA Code Maintenance Committee acted correctly in 2013 when it revised the definition of comprehensive orthodontic therapy. The present (2014) descriptor does not insinuate that comprehensive orthodontics should be expected to yield a lasting result and more accurately reflects the data widely reported by orthodontic researchers.

[1] Kaan M, Madlena M. Retention and Relapse: Review of the Literature. Fogorv Sz. 2011 Dec;104(4):139-46.

[2] 2013 CDBP Code Maintenance Committee (CMC) Action Report; p. 97

[3] Slutzkey S, Levin L. Gingival recession in young adults: Occurrence, severity, and relationship to past orthodontic treatment and oral piercing. Am J Orthod Dentofacial Orthop. 2008 Nov;134(5):652-6. doi: 10.1016/j.ajodo.2007.02.054.

[4] Allen R, Newton C, Brown C. A statistical analysis of surgical and nonsurgical endodontic retreatment cases. J Endo. 1989 Jun;V.15,I(6),:261-6.

[5] Torabinejad M, Corr R, Handysides R, Shabahang S. Outcomes of Nonsurgical Retreatment and Endodontic Surgery: A Systematic Review. J Endo. 2009 Jul;V35(7):930-7.

[6] Yu Y, Sun J, Lay W, Wu T, Koshy S, Z Shi. Interventions for managing relapse of the lower front teeth after orthodontic treatment. Cochrane Database Syst Rev. 2013 Sep 6;9:CD008734. doi: 10.1002/14651858.CD008734.pub2.

[7] Sadowsky C, Saklos E. Long-term assessment of orthodontic relapse. Am J Orthod. 1982 Dec;82(6):456-63.

[8] Littlewood SJ, Millett DT, Doubleday B. Orthodontic retention: a systematic review. J Orthod. 2006 Sep;33(3):205-12.

[9] Bollen AM1, Cunha-Cruz J, Bakko DW, Huang GJ, Hujoel PP. The effects of orthodontic therapy on periodontal health: a systematic review of controlled evidence.  J Am Dent Assoc. 2008 Apr;139(4):413-22.

[10] Valiathan M, Hughes E. Results of a survey-based study to identify common retention practices in the United States. Am J Orthod Dentofacial Orthop. 2010 Feb;137(2):170-7; discussion 177. doi: 10.1016/j.ajodo.2008.03.023.

[11] Lai CS, Grossen JM, Renkema AM, Bronkhorst E, Fudalej PS, Katsaros C. Orthodontic retention procedures in Switzerland. Swiss Dent J. 2014;124(6):655-61.

[12] Alfuriji S, Alhazmi N, Alhamlan N, Al-Ehaideb A, Alruwaithi M, Alkatheeri N and Geevarghese A. The Effect of Orthodontic Therapy on Periodontal Health: A Review of the Literature. Int J Dent. 2014; 2014: 585048. PMC4060421

[13] Casko J, Vaden J, Kokich VG, Damone J, James R, Cangialosi T, Riolo M, Owens S Jr, Bills E. Objective grading system for dental casts and panoramic radiographs. American Board of Orthodontics. Am J Orthod Dentofacial Orthop. 1998 Nov;114(5):589-99.

[14] Grading System for Dental Casts and Panoramic Radiographs. The American Board of Orthodontics. rev. June 2012;1-22.

[15] Santiago J, Martínez C. Use of the Objective Grading System of the American Board of Orthodontics to Evaluate Treatment Outcomes at the Orthodontic Graduate Program Clinic, University of Puerto Rico, 2007-2008. PR Hlth Sci J.prhsj.2012; Vol 31:1.

[16] Song G, Baumrind S, Zhao Z, Ding Y, Bai Y, Wang L, He H, Shen G, Li W, Wu W, Ren C, Weng X, Geng Z, Xu T. Validation of the American Board of Orthodontics Objective Grading System for assessing the treatment outcomes of Chinese patients. Am J Orthod Dentofacial Orthop. 2013 Sep;144(3):391-7. doi: 10.1016/j.ajodo.2013.04.018.

[17] Kassas W, Al-Jewair T, Preston C, Tabbaa S. Assessment of Invisalign treatment outcomes using the ABO Model Grading System. J World Fed Orthodontists. Jun 2013;V2,I2:e61-4.