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Creative Adjuncts for Clear Aligners Part 2 Intrusion, Rotation, and Extrusion

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Creative Adjuncts for Clear Aligners Part 2 Intrusion, Rotation, and Extrusion ©2015 JCO, Inc. May not be distributed without permission. www.jco-online.com Creative Adjuncts for Clear Aligners Part 2 Intrusion, Rotation, and Extrusion S. JAY BOWMAN, DMD, MSD FRANK CELENZA, DDS JOHN SPARAGA, DMD MOSCHOS A. PAPADOPOULOS, DDS, DMD KENJI OJIMA, DDS JAMES CHENG-YI LIN, DDS art 1 in this series of articles (JCO, February however, the application of adjuncts is still indi- P2015) described a number of adjuncts for im- cated in some cases. proving the reliability of Class II treatment with clear aligners. This month, we will demonstrate Intrusion how to perform certain difficult tooth movements with aligners. Part 3 will conclude the series with Intrusion of selected teeth33 or dental seg- a discussion of extraction and interdisciplinary ments,34 as needed in patients with deep overbites, treatment. has been regarded as challenging to perform with One of the most frustrating aspects of clear- clear aligners. In fixed-appliance treatment, mini- aligner treatment has been the unpredictability of screws have been used to assist not only in intru- tooth movements such as dental extrusion, resolu- sion of single posterior teeth for subsequent pros- tion of rotations, and correction of deep overbites. thetic restorations,35 but in mass intrusion to help For example, Chisari and colleagues reported that close anterior open bites and correct deep over- only 57% of the programmed movement of a sin- bites.22,36,37 It seems logical to extend the applica- gle incisor was actually achieved over an eight- tion of skeletal anchorage into the realm of clear week experimental period.31 Kravitz and col- aligners. leagues found only a mean 41% accuracy.32 As Overeruption of teeth with no opponents is treatment progresses, this lag in tooth movement commonly seen in mutilated dentitions. Intrusion can be compounded, resulting in a “tracking error” of a hypererupted tooth is one way to provide suf- that is usually first noticed as an “air gap” between ficient clearance for prosthetic replacement. Mini- the incisal edges of the incisors and the aligner screws are ideally suited to such a task, since a trays. This situation may spread to other teeth, variety of forces (elastic chain, coil springs, or until the trays no longer fit snugly or the intended elastics) can be applied to predictably guide the tooth movement is adversely affected. Newer plas- programmed intrusion without affecting adjacent tic materials, more accurate digital scans, new teeth, even when using clear aligners (Fig. 8).37,38 attachment designs, and better programming strat- Intrusion of multiple teeth to correct deep egies for treatment planning (including the neces- overbites has been acknowledged as a more chal- sity of overcorrection) have improved the predict- lenging and less predictable aspect of clear-align- ability of outcomes. As we discussed in Part 1, er treatment.34 The importance of resolving deep 162 © 2015 JCO, Inc. JCO/MARCH 2015 Dr. Bowman is a Contributing Editor of the Journal of Clinical Orthodontics; an Adjunct Associate Professor, St. Louis University, St. Louis; a straight-wire instructor, University of Michigan, Ann Arbor, MI; an Assistant Clinical Pro fessor, Case Western Reserve Uni versity, Cleveland; a Visiting Clinical Lecturer, Seton Hill University, Greens burg, PA; and in the private practice of orthodontics at 1314 W. Milham Ave., Portage, MI 49024; Drs. Celenza, Sparaga, and Ojima are in the private practice of orthodontics in New York City; Anchorage, AK; and Tokyo, re­­spectively. Dr. Papadopoulos is Professor and Program Director, De­­partment of Orthodontics, School of Dentistry, Aristotle University of Thes saloniki, Thessaloniki, Greece. Dr. Lin is Clinical Assistant Professor, De­­partment of Orthodontics and Pediatric Dentistry, School of Dentistry, National Defense Medical University, Taipei, Taiwan, and in the private practice of orthodontics and implantology in Taipei. Dr. Bowman is inventor of the Clear Collection pliers and Aligner Chewies. E-mail him at [email protected]. Dr. Bowman overbites has become more apparent in recent A years with the increasing percentage of adult orthodontic patients—especially those with re- stricted anterior function, resulting in severe enam- el attrition of both the incisal edges and the labial and lingual tooth surfaces. Recent improvements in aligner program- ming have been designed to assist in leveling the curve of Spee with incisor intrusion and premolar or molar extrusion.39 These include biteplanes molded into the aligner trays behind the upper B anterior teeth and bonded attachments used to deliver extrusive forces to the premolars. Since miniscrew anchorage has been highly dependable in correcting deep bites and “gummy smiles”, it has inevitably been applied to similar treatments with clear aligners (Fig. 9).36-38 C Rotation and Extrusion Fig. 8 Molar intrusion supported by miniscrew Dental rotations and extrusion of anterior anchorage and elastics. A. Adult patient with missing lower right first molar and overerupted teeth seem to be the least predictable aligner move- upper second premolar, initially treated with ments. Kravitz and colleagues found that extrusion chain elastic from miniscrew to bonded button was the least accurate tooth movement in aligner on premolar. B. During later Invisalign phase, treatment, at 29.6% effectiveness.32 Reasons for intramaxillary triangle elastics worn from mini- these difficulties, along with strategies to improve screw to bonded buttons on aligners, ensuring 40 proper tray seating and consistent leveling of oc- rotation control, have been proposed by Nicozisis clusal plane. C. Resulting slight overcorrection and Humber.41 We have incorporated several of provided sufficient clearance for implant in 14 their common themes in the following suggestions: weeks of treatment. VOLUME XLIX NUMBER 3 163 Creative Adjuncts for Clear Aligners A B Fig. 9 Deep-bite treatment with anterior intrusion. A. Adult male patient with mutilated dentition and deep overbite associated with significant anterior wear before treatment. B. Miniscrews inserted between roots of upper lateral incisors and canines for anchorage of intrusion elastics (continued on next page). 164 JCO/MARCH 2015 Bowman, Celenza, Sparaga, Papadopoulos, Ojima, and Lin C D Fig. 9 (cont.) C. Elastic hook formed by placing circular extrusion in facial aligner surface with Hilliard Thermoplier Hook-Forming Pliers,§ then notching half of plastic extrusion with cutting tool. D. Improve- ment in overbite after 22 months of treatment and 35 pairs of aligners. §Registered trademark of Dentsply Raintree Essix Glenroe, Sarasota, FL; www.essix.com. VOLUME XLIX NUMBER 3 165 Creative Adjuncts for Clear Aligners 1. To open sufficient space adjacent to the af- fected tooth, program a visible opening of .25- .5mm into the aligner treatment and/or use inter- proximal reduction. 2. Design appropriate bonded attachments to elic- it rotational and/or extrusive forces.9,42,43 3. Program overcorrection into the aligners to ac- count for the flexibility of the plastic. 4. Use detailing pliers such as Clear Collection’s The Vertical*** and The Horizontal*** to accen- tuate rotational or extrusive couples. 5. Supplement treatment with bonded buttons and elastics or even fixed appliances before or after aligner therapy. 6. Due to the inherent risk of rotational or vertical relapse, discuss the need for supracrestal fiberot- omy (Edwards procedure44) and long-term fixed retention as part of informed consent. The failure of upper lateral incisors to track properly, commonly seen with Class II, division 2 malocclusions, is especially disconcerting. In some instances, the central incisors would benefit from intrusion while the lateral incisors require extru- sion and rotation. Combining selective intrusion, extrusion, root torque, and rotation of anterior teeth requires more than just casual approval of a tech- nician’s programmed treatment plan. Fig. 10 Chewies§ tray seater positioned at “air Failure to address the arch-length discrep- gap” between incisal edge and aligner. ancy before initiating any movement of the lateral incisors is likely to result in disappointment. If extrusion is attempted with insufficient adjacent in place, the patient bites down repeatedly on the space, iatrogenic intrusion may occur as the tooth soft Chewies, each the size of a cotton roll, for is inadvertently “squeezed” apically. Space open- several minutes a day to help seat the aligners, ing also increases the tooth-surface area for the especially as each new pair is started. Chewies are plastic to contact—an important consideration also prescribed when an air gap develops at the with a small, blade-shaped lateral incisor. The ad- incisal edges. In that case, the Chewie should be dition of bonded attachments on the lingual or positioned directly over the affected region to fo- facial surfaces or both should be considered to cus the chewing forces, with the patient holding increase the contact surface area and produce ex- the device solidly between the teeth for 10-15 sec- trusive and/or rotational forces. If tracking is still onds, releasing, and repeating for about five min- lagging behind, other adjuncts can be considered. utes twice a day. Aligner Chewies§ are one of the earliest methods developed to overcome poor tracking or “aligner lag” (Fig. 10).45 Like sequential aligners ***Clear Collection, Hu-Friedy Manufacturing Co., Chicago, IL; www.hu-friedy.com. themselves, these simple devices were based on §Trademark of Dentsply
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