InBrace has grown and matured into a robust system that is predictable and efficient when these 10 Commandments are followed.
By Robert Lee, DDS, MS
Over the past 10 years, the popularity of InBrace has significantly grown, establishing itself as the third category of orthodontic treatment alongside traditional braces and clear aligners. While all three modalities of orthodontic treatment adhere to standard orthodontic biomechanics and principles, each treatment modality has its respective nuances that lead to predictable and efficient treatment. This article introduces 10 simple rules to help master the nuances of InBrace treatment.
1. Thou shalt trust the InBrace Intelligent Force System
Similar to all orthodontic treatment modalities, InBrace requires overcorrection to increase the force level for certain tooth movements and to counteract unfavorable side effects of any planned mechanics or tooth movements. Because there are nuances in overcorrection with InBrace that differ from other orthodontic treatment modalities, it created a learning curve for most orthodontists. To ease this learning curve for their orthodontic providers, InBrace developed its Intelligent Force System (IFS). IFS is an overcorrection algorithm developed through extensive testing and data analysis from thousands of InBrace cases. IFS has been found to improve the predictability of tooth movement and reduce negative side effects for InBrace.
Orthodontists are given the control to opt in or out of IFS through their Smile Design preferences. However, it is highly recommended to opt into IFS and trust the system, as this choice will lead to a smoother and more successful InBrace treatment experience.
2. Thou shalt use the InBrace recommended materials
Every orthodontic treatment modality relies on specific materials to improve their predictability and efficiency. For example, chewies are used specifically with clear aligners to improve aligner seating. Similarly, there are specific recommended materials that are necessary to use InBrace more effectively and are documented on a required materials guide given to all InBrace providers.
Three noteworthy materials that InBrace providers should purchase are Telio Inlay, freeze spray, and the Smartwire plier. Telio Inlay is a temporary filling material used to create flexible anterior bite turbos and will be discussed further in Commandment #6. Freeze spray is used to soften the heat activated InBrace Smartwire, facilitating easier engagement in crowded situations. This is particularly crucial when working on the narrower lingual archform. The Smartwire plier is essential for removing a debonded bracket from the Smartwire and aids in disengaging the Smartwire in more complex situations, such as when the bracket has significant calculus buildup.
3. Thou shalt provide proper post-fitting instruction to the patient
Every orthodontic treatment modality has specific instructions that are given to patients to enhance their at-home experience. The instructions for InBrace patients are outlined in a post-fitting instruction sheet given to every patient, and they are similar to traditional braces with a few key additions.
Initial discomfort from fixed appliances and tooth movement is common in orthodontics, and like traditional braces, over-the-counter pain medication and wax can be used. An additional recommended product for patients to use with InBrace is an over-the-counter oral mouth sore rinse. The oral mouth sore rinse should be used from the beginning of InBrace treatment as a preventative measure and to help soothe any soft tissue irritation that may occur.
Oral hygiene instructions for traditional braces and InBrace are similar, but an additional oral hygiene tool that is highly recommended for InBrace patients is a water flosser. Several portable and affordable water flosser options are now available on the market.
Patients should be mentally prepared for what to expect with orthodontic tooth movement. With all orthodontic treatment modalities, spaces may form when teeth derotate and upright. However, because InBrace is the only modality that has nothing blocking the front of the teeth, patients may find any spaces forming alarming. This may lead them to schedule emergency appointments when they are not aware that such spaces are normal in orthodontic treatment. Mentally preparing patients for potential occurrences during their treatment can help prevent frustration and unnecessary emergency appointment requests.
4. Thou shalt follow the recommended InBrace treatment sequence
With traditional braces, most clinicians follow a standard sequence to improve the consistency and efficiency of their office workflow. Similarly, InBrace has a standard treatment sequence that makes treatment outcomes more predictable and efficient when followed.
The InBrace system has been divided into three treatment stages: Stage I, Stage II, and the optional Digital Enhancement (Figure 1). Each treatment stage has its respective purpose with defined goals that must be achieved before proceeding to the next stage. In addition, each stage has its respective Smartwires that progress in chronological order and must be given sufficient time to fully express before transitioning to the next Smartwire. Understanding and following the recommended treatment sequence guide clinicians on what to do in each appointment and when to execute each step. One common reason for inefficient treatment with InBrace is the omission or delayed execution of steps, so it is essential to understand and follow the recommended InBrace treatment sequence.
5. Thou shalt bond all brackets to their planned bracket positions
For InBrace to work successfully, the brackets must be positioned properly. The InBrace Smartwire is designed from the virtually planned bracket positions that are placed on the doctor approved InBrace Smile Design (digital setup). Any physical deviation in bracket position from the virtually planned bracket positions will cause the Smartwire to express unplanned tooth movement.
When dealing with the narrower lingual archform in crowded situations, there are often brackets that cannot be bonded to their planned bracket position at the beginning of treatment. In such cases, any prescribed IPR should be performed early, and InBrace has different strategies to activate the Smartwire to create space for brackets to be bonded to their planned bracket positions. Before advancing to Stage II in the treatment sequence, it is crucial to check that all brackets are placed in their planned bracket positions. Skipping this step and leaving brackets off center is one of the most common reasons for inefficient treatment with InBrace.
6. Thou shalt use flexible anterior bite turbos
Occlusal interferences with InBrace brackets are common in the beginning of treatment and may lead to bond failure, Smartwire breakage, and enamel wear. Hence, it is critical to place bite turbos when necessary. Posterior bite turbos are recommended in open bite cases and flexible anterior bite turbos are recommended in deep bite cases. Flexible anterior bite turbos are quick and easy to place, and they are more comfortable for patients since they remain partially elastic after curing (Figure 2). They are simple to remove as they can be peeled off with a scaler. When a Smartwire is ready to be changed, flexible anterior bite turbos must be removed, and new ones should be placed back on if still needed.
7. Thou shalt use lighter elastics
All InBrace Smartwires are multi-loop NiTi archwires, so they do not have the same rigidity as a straight stainless steel archwire to prevent side effects from elastics. Thus, it is essential to lighten the strength of elastics when using InBrace to mitigate side effects. InBrace Smartwires include Smartwire 1, Smartwire 2, and Smartwire 3 with each Smartwire increasing in size and rigidity.
For Class II and Class III elastics, it is recommended to use light (2-3 oz) elastics with Smartwire 1, medium (4-5 oz) elastics with Smartwire 2, and heavy (>6 oz) elastics with Smartwire 3. For vertical elastics, it is recommended to lighten the elastics even further by avoiding elastics in Smartwire 1, light (2-3 oz) elastics with Smartwire 2, and medium (4-5 oz) elastics with Smartwire 3.
close extraction spaces.
8. Thou shalt use auxiliaries and labial segments when applicable
Similar to traditional braces, where auxiliaries are often added to support planned tooth movement, auxiliaries should also be added with InBrace when needed. Auxiliaries and labial segments can often be discreetly placed in areas that are less noticeable to patients when they smile. Common reasons for using labial segments include creating space for lingually blocked-out posterior teeth, titrating space for posterior implants, closing extraction spaces, and leveling and aligning second molars.
Auxiliary appliances are often used with InBrace to achieve greater expansion or provide additional anchorage (Figure 3). When considering anchorage with InBrace, keep in mind that InBrace closes spaces reciprocally, so anchorage needs to be managed from the beginning of treatment. In addition to auxiliary anchorage appliances, early and light elastics can be used to help manage anchorage.
9. Thou shalt follow a “less is more” mentality in the Digital Enhancement Smile Design for finishing
When performing final detailing with traditional braces, a common approach involves adding detail bends only where needed while maintaining the positions of most other teeth. This minimizes reactionary forces and results in more predictable detailing. Similarly, when a case is ready for final detailing with Digital Enhancement, adopting a “less is more” mentality is recommended when adjusting the Digital Enhancement Smile Design. Every adjustment to a tooth in the Digital Enhancement Smile Design directly translates to another wire bend in the Digital Enhancement Smartwires, leading to more reactionary forces and less predictable finishing. Therefore, when performing final detailing with Digital Enhancement, “less is more,” only digitally adjust the teeth that need detailing.
10. Thou shalt use settling and/or active retainers when applicable
In cases with short upper clinical crowns, patients may occlude on their upper anterior brackets in the planned finish. This can be seen in the planned Digital Enhancement Smile Design. In such cases, it may be necessary to debond the upper arch first and put it in a retainer to allow for settling. InBrace can remain on the lower teeth, and buttons or cutouts in the upper retainer may be used to help settle the occlusion (Figure 4).
In some cases, very minor tooth movement may be needed to finish a case, like when only minor spaces remain. In such situations, it can often be more efficient to finish the case with a few active retainers since most patients will be transitioning to full-time retainer wear anyway.OP
Robert Lee, DDS, MS, earned his DDS from the University of California at Los Angeles and his MS and orthodontic certificate from the University of California at San Francisco. He is the co-inventor of InBrace and currently serves as the head of clinical affairs and senior clinical advisor at InBrace. Additionally, he was the principal investigator for the InBrace Generation 2.0 Clinical Trials. He is a diplomate of the American Board of Orthodontics, a clinical assistant professor at UCSF, and works in private practice in Tustin, Calif. Disclosure: Lee has a financial interest in InBrace.
