Powerprox Six Month Braces™ Technique By: Rick DePaul, Jr., DDS
President, Six Month Braces, LLC

Life is full of choices. When a patient comes to your office wanting a nicer smile our choices have traditionally been a porcelain veneer smile, makeover or comprehensive two-year orthodontic treatment. Many patients object to the removal of facial enamel to facilitate veneer placement and many patients will not wear braces for two years. So what can you do? Now you can offer a new alternative: The Powerprox Six Month Braces™ Technique (PPSMB).

The goal of porcelain veneers is to give your patient a great smile, the goal of PPSMB is the same, only instead of preparing teeth and bonding porcelain we move the teeth to their most beautiful position. This allows for a more conservative treatment option for many types of cases including, but not limited to; crowding, spacing, crossbites, deep bites, and open bites (Fig. 1).

Many times we will use PPSMB prior to placing veneers to get a nicer result than we could by using either alone. How many of us have had that nearly impossible veneer case walk through the door where we knew if we could get some tooth movement it would greatly simplify the cosmetics? We all have. By correcting the crowding, lining up the teeth, and opening the bite first; we can reduce the amount of tooth reduction required for our veneers, reduce or eliminate the need for intentional endodontics, and minimize the amount of anterior crown lengthening needed to perfect those cosmetic cases. Simply stated the PPSMB makes those impossible veneer cases easy (Fig. 2).

Reproximation
Many feel crowding is caused by the continual reduction of jaw size in human evolutionary development. Whatever the cause, crowding is a discrepancy between the mesiodistal size of the teeth and the length of the dental arch. It stands to reason, if there is a way to reduce the mesiodistal width of the teeth, you can alleviate crowding in the arch. With PPSMB we gain space locally primarily by interproximal polishing, also known as stripping, or enamel reproximation, or reprox for short. Space is created locally, where it is needed, and the teeth are gently aligned into the newly created space. The use of reprox has been well documented, but we feel we are using it in a new and exciting way to achieve our dramatic results. Reprox is a time-tested technique in orthodontics. Ballard first described Reprox in 1944. Reprox is one of the most conservative methods available to alleviate crowding. In addition to creating space, reprox flattens the contact areas, which increase the stability of the final result. This helps minimize relapse after treatment. Reprox can be performed at any time during the treatment, whenever more space is needed. There are many ways to perform reprox, including diamond strips, or diamond and carbide burs. We have found the most rapid and effective way to reprox is to begin with a diamond disk followed by smoothing with a finishing bur. A diamond strip, or interproximal finishing strip, can be used for final finishing of the interproximal enamel, if desired. This method quickly creates space and smooth edges with no pain to the patient. The only exception to this rule is on rotated teeth where the use of a disk would affect the facial or lingual surface of the teeth. We use a bur and/or a diamond strip in these instances since we want interproximal reduction only. In effect we are “shrinking teeth” mesiodistally in order to align them to their appropriate position. In addition to creating space, reprox also reduces the friction between tooth contacts; this reduces the amount of force the archwire must overcome, allowing for quicker tooth movement. After reprox is completed a fluoride treatment can be given if desired. The diamond disk we currently use for reprox is a: Brasseler #934-220 Lite. It has a thickness of .15 millimeters (Figs. 4 and 5).

The question we are often asked is: How much enamel can you safely remove? Sheridan suggested that 50% of the interproximal enamel could be reduced. Proffit says the teeth can be reduced up to 0.5mm on each side without reaching the dentin. We have found that often you can reprox more than 0.5mm, especially on wide teeth, with no adverse effects. A significant amount of space can be gained by reprox. For example, if you reprox all the contacts from the distal of #6 to the distal of #11 you can often gain up to 7mm of space. This is usually more than enough to correct most crowded cases.

Although we will reprox anywhere we need space, it seems we should reprox where the enamel is thickest. On the upper anterior teeth, the thickest enamel is on the mesial and distal of the canines and the distal surfaces of the central incisors. On the lower anterior teeth, the thickest enamel is on the mesial and distal surfaces of the canines and the distal surfaces of the lateral incisors. Many doctors are concerned that the thinning of enamel will increase the patient’s susceptibility to tooth decay and periodontal disease. In actuality, investigators have reported no increase in either caries or periodontal disease due to a reduced enamel surface. Sheridan stated that no study indicated how much enamel is needed for adequate protection of the teeth. The natural variation in thickness of enamel suggests that there is no protective advantage in preserving thick interproximal enamel when thin enamel occurs naturally on the facial and lingual surfaces of the teeth. Certain studies did show some increased roughness of reproxed enamel when compared to virgin enamel, but there was no increase in decay. In one study El-Mangoury indicated that reprox did not expose enamel to changes that caused caries. There was a period of demineralization followed by remineralization within nine months. Some have suggested placing a sealant after reprox, but this would actually interfere with the constant remineralization that naturally occurs. However, a fluoride treatment can be given after reprox. Craine and Sheridan also demonstrated reproxed teeth are no more susceptible to caries or periodontal disease than unaltered surfaces. When done properly reprox has no negative effects on the bone or interproximal tissue. Tuverson reported a negligible periodontal change and showed gingival papillae that were actually greatly improved after correction of crowding with reprox. In a nine year study Boese found no significant increase in pocket depth, gingival recession or loss of alveolar bone.

Nickel Titanium Archwires
Nickel titanium archwires are critical to the success of PPSMB due to their shape memory, high flexibility and the consistent sustained forces they put on the teeth. All of these properties allow for the ligation of severely malposed teeth and allow them to be gently moved to the desired position quickly and safely (Fig. 6). Nickel titanium archwires are the perfect combination of strength and flexibility (Fig. 7). The main tooth movements used in the PPSMB are tipping, rotations, intrusion, extrusion, with some translation and torquing. Nickel titanium wires are more than adequate to accomplish these movements.

Conclusion
Remember the goal of PPSMB is to give your patients a great smile. No matter what type of malocclusion the patient has, the goal is always the same. Give your patient a great smile. As such PPSMB can be use on a variety of different case types such as crowding, spacing, crossbites, deep bites, and open bites (Figs. 8 and 9).The use of reprox and nickel titanium archwires are just two of the “pieces of the PPSMB puzzle” that we use to give patients the smiles they have always wanted in such a short period of time. The demand for this service is astronomical. Personally, we have treated patients who have driven or flown in from 8 different states to get PPSMB. We had one patient who actually had her phone disconnected to pay for PPSMB. She could not afford both so she opted to straighten her teeth and improve her smile. This shows the level of dedication and motivation present for PPSMB.

Now you have a choice to make. In addition to providing porcelain veneers and comprehensive two-year orthodontics, hopefully you will also offer PPSMB. It is one more “tool in your belt” to help your patients reach their cosmetic goals.

Richard J. DePaul, Jr., DDS graduated in 1994 from Case Western Reserve University. He is the author of the book “The Powerprox Six Month Braces Technique. The Next Step in the Cosmetic Dentistry Revolution.”

Bibliography:
Ballard ML. Asymmetry in tooth size: A factor in etiology diagnosis, and treatment of malocclusion. Angle Orthod 1944;14:67-70.

Sheridan JJ. Air-rotor stripping update. J Clin Orthod 1985;19:43-59.

Sheridan JJ. Air-rotor stripping update. J Clin Orthod 1987;21:781-88.

Proffit WR. Contemporary Orthodontics. Missouri: CV Mosby, 1986.

Peck H, Peck S. Reproximation (enamel stripping) as an essential orthodontic treatment ingredient. C.V. Mosby Co., St Louis, 1975, pp. 513-522.

El-Mangoury NH, Moussa MM, Mostafa YA, Girgin AS. In-vivo remineralization after air-rotor stripping. J Clin Orthod 1991;25:75-78.

Craine G, Sheridan JJ. Suceptibility to caries and periodontal disease after posterior air-rotor stripping. J Clin Orthod 1990;4:84-5.

Tuverson DL. Anterior interocclusal relations: Part 1. Am J Orthod 1980;78:361-70.

Boese LR. Fiberotomy and reproximation without lower retention: Nine years in retrospect. Angle Orthod 1980;50;88-97, 169-178.