10.59987/ads/2023.2.3-6
The primary objective of this study is to evaluate the Tpredictability of orthodontic treatment with clear aligners monitored by Dental Monitoring® (DM) and to assess if using the DM system can actually lead to better results and shorter treatment times. A secondary objective is to assess whether the DM system can be more effective in monitoring one type of malocclusion over another, namely: crowding, crossbite and diastema. A total of 55 patients treated consecutively with clear aligners were selected. All patients were asked to use the DM system with scheduled appointments at 7–8-week intervals. Our results show that photos and scans taken in the chair correspond accurately to the photos and scan taken by the patient using the DM system. Results also show that the different malocclusions did not show any difference in predictability when using the DM system. This study concluded that treatment time was indeed reduced in terms of total number of in-office appointments.
text/html
1971-1441
239
2
en
Vincenzo  D’Antò
https://creativecommons.org/licenses/by-nc-nd/4.0
Annali di stomatologia
treatment plan
The improvement of predictability in Clear Aligner treatment in conjunction with Digital Monitoring
Text.Serial.Journal
https://www.annalidistomatologia.eu/ads
14
Original Article
2023-08-02
2023-08-01
2023-08-02
2023-12-04
3-6
Ann Stomatol (Roma)
Vincenzo  D’Antò
2023/08/02
10.59987/ads/2023.2.3-6
3
School of Orthodontics, Department of Neuroscience, Reproductive Science and Oral Science, University of Naples Federico II, 80131 Naples, Italy
1971-1441
2
treatment plan
en
6
The improvement of predictability in Clear Aligner treatment in conjunction with Digital Monitoring
https://www.annalidistomatologia.eu/ads/article/view/239/248
14
                                                                                                    Original Article


The improvement of predictability in Clear Aligner
treatment in conjunction with Digital Monitoring



Sara Caruso*1                                                 sential to guide the patient and follow their compliance
Silvia Caruso1                                                in order to obtain the most beneficial results from the
Mariaelena De Felice1                                         treatment. Dental Monitoring (DM) is a recent invention
Roberto Gatto1                                                that combines teleodontology with artificial intelligence
Vincenzo D’Antò2                                              (AI) and allows orthodontists to monitor their patients’
                                                              treatment progress remotely using the patient’s own
1
    Department of Life, Health and Environmental Scienc-      smartphone to take photographs or scans. Furthermore,
    es, Paediatric Dentistry, University of L’Aquila, 67100   the DM software can build three-dimensional (3D) digi-
    L’Aquila, Italy                                           tal models from these scans. [7] The program consists
2
    School of Orthodontics, Department of Neuroscience,       of three integrated platforms: 1) a phone application
    Reproductive Science and Oral Science, University of      for the patient, 2) a patented algorithm that evaluates
    Naples Federico II, 80131 Naples, Italy                   orthodontic movements and 3) a web platform where
                                                              professionals receive updates on the evolution of their
                                                              patients’ treatment. When patients take scans, the im-
*Corresponding author: saracaruso2704@gmail.com               ages are uploaded to the program’s servers and verified
                                                              to ensure that their quality is sufficient to be processed
Abstract                                                      by the Dental Monitoring algorithm, which can calculate
                                                              tooth movement with high precision. [3]. In orthodon-
The primary objective of this study is to evaluate the        tics, the DM system allows the treating doctor to mon-
Tpredictability of orthodontic treatment with clear           itor the loss or detachment of brackets, tubes, bands
aligners monitored by Dental Monitoring® (DM) and             and buttons, injuries from broken hooks or temporary
to assess if using the DM system can actually lead            anchoring devices (TAD), broken ligatures, escape of
to better results and shorter treatment times. A sec-         the arch occlusal interference with a tooth or a brack-
ondary objective is to assess whether the DM system           et, oral hygiene, soft tissue inflammation, damage to
can be more effective in monitoring one type of mal-          the teeth, signs of aphthous stomatitis, cleanliness of
occlusion over another, namely: crowding, crossbite           appliances, gum recessions, and stability of fixed and
and diastema. A total of 55 patients treated consec-          removable retainers. In particular, during an orthodontic
utively with clear aligners were selected. All patients       treatment with clear aligners, monitoring can be carried
were asked to use the DM system with scheduled ap-            out at each aligner change, according to the protocol
pointments at 7–8-week intervals. Our results show            chosen by the orthodontist. [9-10]. The DM system no-
that photos and scans taken in the chair correspond           tifies the treating doctor of various data: the “tracking”
accurately to the photos and scan taken by the patient        option allows the clinician to remotely follow the treat-
using the DM system. Results also show that the dif-          ment at each change of aligners, to evaluate the fit of
ferent malocclusions did not show any difference in           the aligner. The option “loss of glued auxiliary” allows
predictability when using the DM system. This study           the doctor to monitor the integrity of the auxiliaries. The
concluded that treatment time was indeed reduced in           “auxiliary device” option can evaluate the presence and
terms of total number of in-office appointments.              maintenance of buttons and elastics. The “damage to
                                                              aligners” option is essential to ensure proper integrity
Keywords: Dental Monitoring; clear aligners; pre-             of the teeth and aligners. The clear aligner system con-
dictability; treatment plan.                                  sists of custom-made aligners that perform orthodontic
                                                              tooth movements by applying compression and traction
Introduction                                                  forces to the periodontium. Optimal tooth movement
                                                              occurs when continuous orthodontic forces are applied
Teleorthodontic technology and remote monitoring of           and maintained, hence, making it necessary to change
patients have become an imminent reality that allows or-      the aligners regularly to counter the effects of aligner
thodontists to proactively monitor their patients through     force degradation and loss of elasticity with in vivo use.
virtual controls that are an integration with those in the    Most clear aligner makers suggest that these chang-
clinic. [2]                                                   es are needed on average after one to two weeks of
Literature suggests that this technology leads to better      wear. Regular replacement of aligners requires a high
clinical outcomes and high patient and physician satis-       level of patient compliance [11-12]. In patients with poor
faction by dramatically reducing chair time. [1]. Since       compliance, treatment times may also increase due to
orthodontic treatment usually lasts for months, it is es-     the need for further refinements which is due, in turn, to


10.59987/ads/2023.2.3-6                                                                                                     3
    The improvement of predictability in Clear Aligner treatment in conjunction with Digital Monitoring

    less-than-ideal results.[13-14].In this retrospective study,   The exclusion criteria were as follows:
    the primary objective is to evaluate the predictability of     • need for orthognathic treatment
    orthodontic treatment with clear aligners monitored by         • anomalies of enamel and dentin.
    DM, and to assess if using the DM system can actual-
    ly lead to better results and shorter treatment times by       Patients were treated by a single orthodontist provider
    monitoring patients closely and more accurately, and fol-      (S.C.) and all patients were asked to use the DM system
    lowing the treatment plan as set up using the Invisalign       at the start of their treatment with scheduled appointments
    ClinCheck® software.                                           at approximately 7-8week intervals. Each group changed
    In our study, the patients were divided into three groups      aligners approximately every 10 days with an average
    corresponding to three different orthodontic problems:         wear of 22h per day. However, this aligner change proto-
    crowding, crossbite and diastema. The secondary ob-            col could vary based on how the DM software instructed
    jective is to assess whether the DM system can be more         the patient as to whether to proceed to the next aligner or
    effective in monitoring one type of malocclusion over          continue wearing the same aligner one or several days
    another.                                                       longer. Frontal and lateral DM scans were processed and
                                                                   compared at time T0 (before treatment) and at time T1
    Materials and Methods                                          (after approximately 12 months of treatment). The DM
                                                                   software highlights at each aligner change both the de-
    A total of 55 patients treated consecutively with clear        gree of gingival inflammation present and the location of
    aligners were selected by the University of L’Aquila of        the various dental misalignments. (Fig.1-2).
    which, 32 belonging to group A: patients with dental           These measurements were verified by two doctors:
    crowding in both arches, 15 to group B: patients with          MEDF and SA.C.
    multiple diastemas, 8 belonging to group C: patients with
    anterior crossbite, unilateral or bilateral. Patients were
                                                                   Results
    followed up with Dental Monitoring (DM) during the ap-
    proximately 12-month course of treatment and have the          The scans obtained using the DM application at time T0
    following inclusion criteria:                                  and T1 were then compared. We found excellent corre-
    • treatment with at least 20 clear aligners in the first       lation in the first year of therapy between clinical teeth
        treatment phase                                            alignment and the planned alignment in the ClinCheck®
    • non-extraction treatment                                     treatment plan. (Fig.3-8). During the course of treatment,
    • patients with full permanent dentition                       the “negative” comments provided by the DM system,
    • patients who did not have agenesis or other dental           which indicated poor oral hygiene or a lack of aligner
        anomalies.                                                 tracking, made it possible to immediately identify the




    Figure 1. Platform of DM of the first case



4                                                                                                         10.59987/ads/2023.2.3-6
S. Caruso et al.




Figure 2. Platform of DM of the second case




Figure 3. Pre-treatment of crossbite case     Figure 5. Pre treatment of diastema case




Figure 4. Post treatment of crossbite case    Figure 6. Post treatment of diastema case



10.59987/ads/2023.2.3-6                                                                   5
    The improvement of predictability in Clear Aligner treatment in conjunction with Digital Monitoring

                                                                   Hansa et. al, measuring the effect of treatment monitor-
                                                                   ing with DM, recorded a reduction in treatment time of
                                                                   1.8 months for patient using the DM system. In addition,
                                                                   a reduction in appointments of 33.1% over the total dura-
                                                                   tion of treatment was recorded in the study. Patients with
                                                                   crowded dentitions showed a prevalence of negative
                                                                   comments regarding poor oral hygiene. The first set of
                                                                   aligners was completed without the need to interrupt the
                                                                   treatment and perform a refinement ahead of schedule.

                                                                   Conclusions
                                                                   This study showed that therapy time was reduced in terms
    Figure 7. Pre treatment of crowding case
                                                                   of the number of appointments and this indicates that there
                                                                   is also a reduction in material costs and number of visits.
                                                                   In addition, there is an increase in the frequency of patient
                                                                   monitoring, resulting in a more accurate assessment of the
                                                                   treatment by the orthodontist. Furthermore, these results
                                                                   reveal an important precision in terms of the development
                                                                   of the DM system that allowed the doctor to follow the pa-
                                                                   tients remotely, achieving the pre-established objectives.
                                                                   The limit of the study refers to the lack of occlusal scans
                                                                   of the dental arches and therefore to a lack of overlap with
                                                                   the digital models processed by the 3D scanner.


                                                                   References
                                                                   1.    Mandall NA, O’Brien KD, Brady J, Worthington HV, Harvey L.
    Figure 8. Post treatment of crowding case                            Teledentistry for screening new patient orthodontic referrals.
                                                                         part 1: a randomised controlled trial. Br Dent J 2005; 199:659-
                                                                         62: discussion 653.
    problem and make corrective measures. In addition, the         2.    Nutalapati R, Boyapati R, Jampani N, Dontula BSK. Applica-
    proper wear of the aligners, and the correspondence of               tions of teledentistry: a literature review and update. J Int Soc
    the photos taken in the dental chair with those of the               Prev Community Dent. 2011;1(2):37.
                                                                   3.    Hansa I, Semaan SJ, Vaid NR, Ferguson DJ. Remote monitor-
    application were compared at each appointment, detect-
                                                                         ing and “Teleorthodontics”: concept, scope and applications.
    ing an almost total correspondence between both sets of              Semin Orthod. 2018;24(4): 470–81.
    photographs. Our study evaluated whether there were            4.    Chen JW, Hobdell MH, Dunn K, Johnson KA, Zhang J. Tele-
    differences in the predictability of treatment based on              dentistry and its use in dental education. J Am Dent Assoc
    the different malocclusions. The results showed that the             2003;134:342-6.
    malocclusions did not show any difference in predictabil-      5.    Jampani ND, Nutalapati R, Dontula BSK, Boyapati R. Applica-
    ity over the first year of therapy.                                  tions of teledentistry: a literature review and update. J Int Soc
                                                                         Prev Commun Dent 2011;1:37-44.
                                                                   6.    Kravitz ND, Burris B, Butler D, Dabney CW. Teledentistry, doit-
                                                                         yourself orthodontics, and remote treatment monitoring. J Clin
    Discussion                                                           Orthod 2016;50:718-26.
                                                                   7.    Impellizzeri A, Horodynski M, Serritella E, et al. Threedimen-
    Treatment with clear aligners requires careful and                   sional evaluation of dental movement in orthodontics. J of
    thoughtful digital planning in order to achieve successful           Dentalcad 2020;88(3):182-190
    dental movements throughout treatment until the finish-        8.    Morris RS, Hoye LN, Elnagar MH, Atsawasuwan P, Galang-
    ing stage and make this technique more predictable. In               Boquiren MT, Caplin J, et al. Accuracy of Dental Monitoring 3D
    our study, the patients recruited and subjected to ortho-            digital dental models using photograph and video mode.Am J
                                                                         Orthod Dentofacial Orthop 2019;156:420-8.
    dontic treatment with clear aligners were monitored using
                                                                   9.    Grauer D, Cevidanes LH, Tyndall D, Styner MA, Flood PM,
    the DM system where a sequence of scans were gener-                  Proffit WR. Registration of orthodontic digital models. Cranio-
    ated that corresponded to the various treatment phases.              fac Growth Ser 2011;48:377-91.
    The primary objective was to evaluate the predictability       10.   Grunheid T, Loh C, Larson BE. How accurate is Invisalign in
    of orthodontic treatment with clear aligners monitored by            nonextraction cases? Are predicted tooth positions achieved?
    DM and to assess if using the DM system can actual-                  Angle Orthod 2017;87:809-15.
    ly lead to better results and shorter treatment times by       11.   Tuncay, O.C.; Bowman, S.J.; Nicozisis, J.L.; Amy, B.D. Effec-
                                                                         tiveness of a compliance indicator for clear aligners. J. Clin.
    following patients closely and more accurately, and fol-             Orthod. 2009, 43, 263–268.
    lowing the treatment plan as setup using the ClinCheck®        12.   Schott, T.C.; Göz, G. Color fading of the blue compliance indi-
    software. The results obtained in our study are in agree-            cator encapsulated in removable clear Invisalign Teen ®align-
    ment with the literature [8,3] as they demonstrated excel-           ers. Angle Orthod. 2011, 81, 185–191.
    lent therapy control and a correspondence between the          13.   Al-Abdallah, M.; Hamdan, M.; Dar-Odeh, N. Traditional vs
    scans performed through the application and the office               digital communication channels for improving compliance
                                                                         with fixed orthodontic treatment: A randomized controlled trial.
    visits with intervals of 7-8 weeks. Furthermore, the study
                                                                         Angle Orthod. 2021, 91, 227–235.
    showed that after about 12 months, the scans obtained          14.   Richter, D.D.; Nanda, R.S.; Sinha, P.K.; Smith, D.W.; Currier,
    using the DM application showed excellent results for                G.F. Effect of behavior modification on patient compliance in
    all three monitored malocclusions. [4,5,6]. The study by             orthodontics. Angle Orthod. 1998, 68, 123–132.



6                                                                                                              10.59987/ads/2023.2.3-6
