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Creative Adjuncts for Clear Aligners Part 3 Extraction and Interdisciplinary Treatment

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Creative Adjuncts for Clear Aligners Part 3 Extraction and Interdisciplinary Treatment ©2015 JCO, Inc. May not be distributed without permission. www.jco-online.com Creative Adjuncts for Clear Aligners Part 3 Extraction and Interdisciplinary Treatment S. JAY BOWMAN, DMD, MSD FRANK CELENZA, DDS JOHN SPARAGA, DMD MOSCHOS A. PAPADOPOULOS, DDS, DMD KENJI OJIMA, DDS JAMES CHENG-YI LIN, DDS n Part 1 of this series (JCO, February 2015), we Extraction Treatment Idiscussed the use of various adjuncts in Class II Clear-aligner treatment of severe dental pro- treatment with clear aligners. Part 2 (JCO, March trusion and/or crowding has been a challenge be- 2015) showed how to use aligners for intrusion, cause of such problems as anchorage requirements, rotation, and extrusion. This month, we conclude control of the occlusal plane and vertical dimen- with demonstrations of the issues involved in ex- sion, anterior torque, and tipping of teeth into ex- traction treatment, torque control, and interdisci- traction sites—although favorable results have plinary treatment with clear aligners. certainly been reported.53-56 Unless reciprocal space closure is desired, anchorage reinforcement is a necessity. This can take many forms, from the addition of elastics to the initial placement of par- tial fixed appliances57 to the use of full fixed ap- Dr. Bowman is a Contributing Editor of the Journal of Clinical Orthodontics; an pliances for a portion of treatment before or after Adjunct Associate Professor, St. Louis aligner therapy. Considering the complexity of University, St. Louis; a straight-wire instructor, University of Michigan, Ann extraction biomechanics with clear aligners, any Arbor, MI; an Assistant Clinical Pro- treatment plan will require careful customized fessor, Case Western Reserve Uni- 58 versity, Cleveland; a Visiting Clinical staging, as described by Samoto and Vlaskalic, Lecturer, Seton Hill University, Greens- perhaps combined with the previously discussed burg, PA; and in the private practice of 59,60 orthodontics at 1314 W. Milham Ave., adjuncts—especially miniscrew anchorage. Portage, MI 49024; Drs. Celenza, Miniscrews can provide indirect posterior Sparaga, and Ojima are in the private practice of orthodontics in New York anchorage by holding the molars in position while City; Anchorage, AK; and Tokyo, re - the retraction is directed by clear aligners (Fig. 18). spectively. Dr. Papadopoulos is Professor and Program Director, De - Temporary implants may also be used as “posts” partment of Orthodontics, School of for the application of intramaxillary and/or inter- Dentistry, Aristotle University of Thes- saloniki, Thessaloniki, Greece. Dr. Lin is maxillary elastics to support space closure, im- Clinical Assistant Professor, De partment prove a Class II relationship, or correct a deep of Orthodontics and Pediatric Dentistry, School of Dentistry, National Defense overbite (Figs. 3,19,20). Medical University, Taipei, Taiwan, and Although lingual appliances represent an- in the private practice of orthodontics and implantology in Taipei. E-mail Dr. other esthetic alternative, a transition from pre- Bowman at [email protected]. Dr. Bowman liminary treatment with full lingual brackets to VOLUME XLIX NUMBER 4 © 2015 JCO, Inc. 249 Creative Adjuncts for Clear Aligners A B Fig. 18 Extraction treatment with indirect miniscrew anchorage. A. Adult female patient with crowded and protrusive dentition before treatment. B. After extraction of upper and lower first premolars and insertion of miniscrews between upper second premolars and first molars. Sectional wires bonded to buccal sur- faces of first molars and heads of miniscrews provide indirect anchorage for retraction with aligners (con- tinued on next page). Invisalign* would be highly unlikely due to the of clear aligners (Fig. 20). In addition, there are costs and discomfort involved. Nevertheless, it ongoing investigations of the effectiveness of de- seems reasonable in an extraction case to take ad- vices such as AcceleDent**61,62 (Fig. 21), Pro- vantage of miniscrew anchorage for a substantial pel,*** and OrthoPulse† in accelerating the rate amount of retraction and space closure with partial of tooth movement during clear-aligner therapy. fixed lingual mechanics prior to the introduction 250 JCO/APRIL 2015 Bowman, Celenza, Sparaga, Papadopoulos, Ojima, and Lin C Fig. 18 (cont.) C. Patient after 25 months of clear-aligner treatment. Anterior and Posterior Torque tended side effect of the anterior torque was a The inability to apply anterior lingual root notable iatrogenic “rotation” (mesial tipping) and torque was originally considered to be a significant concomitant distal root rotation of the maxillary first molars (Figs. 3C,6D,22A). limitation of clear aligners.63,64 During the Invis- Torquing moments of couple at the incisors align TEEN* research project,13 however, the ad- dition of “torque ridges” to enhance lingual crown create moments of force at the distal aspects of the torque on the upper incisors was found to be effec- anchoring first molars—a mesial force transmitted tive (although the positive results may have been throughout the dental arch. Although the same influenced somewhat by the unprecedented atten- biomechanical situation occurs with traditional brackets, it can be counterbalanced by using crown tion given to this aspect of tooth movement).64 During that preliminary investigation, an unin- tipbacks or perfectly placed and tied-back omega stops in the archwire, or by other means of anchor- age support. If the wire is not tied to the molars, *Registered trademark of Align Technology, Inc., Santa Clara, the incisors will flare. Consequently, forces trans- CA; www.aligntech.com. **Registered trademark of OrthoAccel Technologies, Bellaire, mitted through the wire will produce a force at the TX; www.acceledent.com. distal aspect of the molar, perpendicular to the ***Trademark of Propel Orthodontics, Briarcliff Manor, NY; first-molar trifurcation, and a moment of force will www.propelorthodontics.com. †Trademark of Biolux Research Ltd., Vancouver, BC, Canada; rotate (tip) the molar forward. www.bioluxresearch.com. If the force of occlusion is coupled through VOLUME XLIX NUMBER 4 251 Creative Adjuncts for Clear Aligners Fig. 19 Deep-bite extraction treatment supported by miniscrew anchorage. A. 45-year-old male patient with unilateral Class II maloc- clusion, crowding, deep overbite, and significant anterior tooth wear before treatment (continued on next page). A 252 JCO/APRIL 2015 Bowman, Celenza, Sparaga, Papadopoulos, Ojima, and Lin B C C Fig. 19 (cont.) B. After extraction of upper right second premolar, two miniscrews inserted in anterior al- veolus of each arch to support intrusion elastics worn to hooks formed in aligners (see Figure 9). C. After 29 months of treatment with 39 upper and 29 lower aligners, showing substantial improvement in overbite, crowding, midline, extraction-space closure, and clearance for restoration of lower anterior teeth. VOLUME XLIX NUMBER 4 253 Creative Adjuncts for Clear Aligners A B C D Fig. 20 Extraction treatment supported by miniscrew anchorage and elastics. A. 54-year-old female pa- tient with significant maxillary crowding and overbite before treatment. B. Upper right first premolar ex- tracted and buccal miniscrew inserted. C. After 24 months of treatment, including retraction supported by Class I intramaxillary elastic from miniscrew to notches in aligner trays mesial to canine. D. After 36 months of treatment, before esthetic restoration of upper right second premolar. 254 JCO/APRIL 2015 Bowman, Celenza, Sparaga, Papadopoulos, Ojima, and Lin clear aligners, any extrusion is prevented by the “passive posterior intrusion” inherent in the long- plastic held between the posterior teeth. There is term wear of two plastic trays, along with the pre- only limited control of intrusion, however, so that viously noted intrusive effects on the first molars the mesial aspects of the molars tend to intrude as during the application of anterior torque. Add in the crowns tip forward. When anterior lingual root the effects of en masse retraction, distalization, or torque is applied with clear aligners, this unin- extractions, and the development of posterior open tended lack of occlusion of the upper molars’ in- bites becomes almost inevitable. terproximal marginal ridges must be counteracted Align Technologies’ new ClinCheck Pro En- with a balancing distal crown rotation (tip) of the hancements* software permits the orthodontist to molars (Fig. 22B). That may involve programming adjust individual root torque in an aligner prescrip- a mesial extrusion of the molars (mesial tip of the tion.72 Specifically, the clinician can alter poste- first molar roots), perhaps in conjunction with rior buccolingual inclinations, improve bucco- prominent horizontal rectangular attachments on lingual cusp heights, or change the curve of Wilson the molars. in the dental setup (Fig. 23). The occlusion can In 1996, as the basis for an Objective Grad- also be finished by cutting away posterior seg- ing System, the ABO determined the most com- ments of the aligner trays to permit “passive set- mon mistakes made by candidates who had failed tling” or by adding intermaxillary elastics, making the Phase III examination.65 Improper bucco- occlusal adjustments, or even prescribing custom lingual inclination in the posterior dentition was tooth positioners. Another option with the Pro the most frequently noted error.65-67 According to Enhancements software is to increase posterior Marshall and colleagues, “For proper occlusion, occlusal “collisions”
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