Successful Treatment of an Adult Patient with Class Iii Malocclusion and Open Bite Using the Invisalign System

CASE REPORT

SUCCESSFUL TREATMENT OF AN ADULT PATIENT WITH CLASS III DR SARAH MALOCCLUSION AND LAWRENCE BDS (Otago), OPEN BITE USING THE MDSc (Melbourne) INVISALIGN SYSTEM

This case report is intended for dental and healthcare professionals, and is subject to applicable local laws, regulations and guidelines. INVISALIGN, CLINCHECK, and ITERO ELEMENT, among others, are trademarks and/or service marks of Align Technology, Inc. or one of its subsidiaries or affiliated companies and may be registered in the U.S. and/or other countries. Science in Every Smile ZK was a 34-year-old male who presented for an orthodontic consultation. ZK’s presenting CLINICAL FINDINGS the lower midline with IPR. The upper and Attachments lower buccal segments were actively extruded • Class III molar and canine relationship on Initial aligners: to help to improve occlusal interdigitation. complaint was an uneven smile. During a previous orthodontic consultation elsewhere he was right side • Optimised Multi-tooth Extrusion Class III elastics were continued throughout Attachments – for extrusion upper 2-2 recommended fixed appliances in combination with bimaxillary orthognathic surgery for the • Class I molar and canine relationship on the refinement. left side • Optimised Root Control Attachments At the conclusion of the first refinement, the Class III facial asymmetry. At the age of 10 years old, he underwent maxillary expansion with a • Conventional attachments • –1 mm overjet upper and lower midlines were essentially rapid palatal expander. • 0 mm overbite coincident and the bite and buccal occlusion First refinement: • Anterior crossbite had improved, but there were still some • Optimised Root Control Attachments – for detailed finishing • Spacing present in upper and lower arches anterior interferences and the buccal occlusion was still open. The second and final • Conventional attachments – for active • Lack of incisal display and reverse smile refinement (additional refinement number 2), extrusion buccal teeth • 1.5 mm lower midline discrepancy to left aimed to further procline the upper incisors Second refinement: • Mandibular asymmetry – chin point to left and again actively extrude the posterior • Optimised Root Control Attachments buccal teeth. Elastic cut-outs were placed • Optimised Rotation Attachments and elastics continued through to refinement TREATMENT GOALS • Optimised Deep Bite Extrusion number 2. As G5 advancements were Attachments – to help extrude • To provide a positive overjet and overbite introduced by Align Technology, Inc. at this lower premolars • To extrude upper anterior teeth to improve time, G5 Optimised Attachments were used • Power Ridges – for anterior root torque incisal display and smile line in the lower arch to help to extrude the lower • To camouflage Class III malocclusion and premolars to improve occlusal contact with Retention mandibular asymmetry using Class III the upper premolars. elastics and interproximal reduction (IPR) as • Nightly upper and lower Vivera retainers required to avoid orthognathic surgery TREATMENT DETAILS • To utilise Invisalign aligners to control the TREATMENT OUTCOME Active Treatment Time PRE-TREATMENT vertical dimension by occlusal coverage to The result for ZK is pleasing both occlusally avoid inadvertent bite opening anteriorly 22 months. and aesthetically. The patient is extremely while precisely controlling the angulations happy since his chief complaint of having of the anterior teeth Aligners Used an uneven smile was addressed without Initial stage: orthognathic surgery. After the last refinement, CLINICAL PRESENTATION the patient stated that his “bite felt just right”. TREATMENT APPROACH • 24 upper aligners The patient is a good gauge (as well as the ZK presented with a Class III In this case, the Class III anterior open bite • 24 lower aligners use of articulating paper) as to when you have was corrected by a combination of absolute First refinement: achieved even occlusal contacts. skeletal malocclusion, anterior active extrusion of the upper anterior teeth • 9 upper and lower aligners ZK was highly motivated throughout the as well as incisor proclination. Retraction of entire treatment. He wore elastics consistently Second refinement: open-bite tendency with lower anterior teeth using existing space throughout the treatment. This coupled with mandibular asymmetry and lower as well as space gained by performing IPR • 15 upper and lower aligners excellent aligner wear resulted in a successful FIGURE 1. INTRA- AND EXTRA-ORAL IMAGES BEFORE TREATMENT and Class III elastic wear contributed to the dental midline discrepancy. correction of the anterior open bite. The patient was advised that the lower midline discrepancy may not be corrected due to the mandibular asymmetry, but the aim in the initial ClinCheck Plan was to correct this using Class III elastics. The aligners were changed every 2 weeks and the Class III elastics were commenced at aligner no. 6 in the initial ClinCheck Plan. The elastics were run off elastic cut outs on the lower first premolars to buttons on the upper 7s (button cut-outs were placed on upper second molars). The elastics used were 3/16” (3.5 oz). At the end of the first series of aligners some small issues with alignment were present, as well as lack of posterior contact due to anterior interferences. The lower midline was still non-coincident with the upper. The aim FIGURE 3. CEPHALOMETRIC of the first refinement (additional aligners FIGURE 4. INITIAL FIGURE 5. FINAL FIGURE 2. PANORAMIC RADIOGRAPH BEFORE TREATMENT RADIOGRAPH BEFORE TREATMENT number 1) was to align the arches further, CLINCHECK IMAGES CLINCHECK IMAGES retract the lower anterior teeth, and correct

This case report is intended for dental and healthcare professionals, and is subject to applicable local laws, regulations and guidelines. This case report is intended for dental and healthcare professionals, and is subject to applicable local laws, regulations and guidelines. INVISALIGN, CLINCHECK, and ITERO ELEMENT, among others, are trademarks and/or service marks of Align Technology, Inc. or one of its INVISALIGN, CLINCHECK, and ITERO ELEMENT, among others, are trademarks and/or service marks of Align Technology, Inc. or one of its subsidiaries or affiliated companies and may be registered in the U.S. and/or other countries. subsidiaries or affiliated companies and may be registered in the U.S. and/or other countries. Science in Every Smile FIGURE 6. PANORAMIC RADIOGRAPH AFTER TREATMENT

POST-TREATMENT

FIGURE 7. CEPHALOMETRIC FIGURE 8. INTRA- AND EXTRA-ORAL IMAGES AFTER TREATMENT RADIOGRAPH AFTER TREATMENT

anterior teeth is not fully corrected then the lower asymmetry in combination with IPR. outcome. He is currently in retention in an anterior interference can result, which The final photos and radiographs show ZK upper and lower Vivera retainers and the can present clinically as a posterior open to still have a Class III skeletal pattern with occlusion remains stable. I anticipate that the bite. The practitioner should check the bite a mandibular asymmetry. His teeth have Vivera retainers will hold the correction well, with articulating paper at the end of the compensations that have been created to particularly the vertical component due to the treatment. It is also recommended to take help camouflage the discrepancy. The upper nightly occlusal coverage. photos to see clearly where the interference incisors have been proclined, and the lower lies to ensure that this is addressed incisors retroclined. Despite this, ZK has Clinical Tips in the ClinCheck Plan. In the second achieved a great aesthetic outcome and an • The Invisalign appliance, in my opinion, refinement for ZK, the proclination of the excellent functional result. is the ultimate technique for correcting upper incisors on the ClinCheck Plan was a Class III, open-bite malocclusion. This accentuated, which can look odd digitally. Author disclosure is because of the vertical control both This over-correction in the ClinCheck Plan Dr Sarah Lawrence was provided an honorarium from Align through occlusal coverage by the aligners, is not reflected clinically and is in place to Technology, Inc., for her contribution towards the creation of this case report. which avoids inadvertent posterior accommodate for tooth movement lag. extrusion, as well as active extrusion of Dr Sarah Lawrence the upper incisors (aided by Optimised CONCLUSION Sarah Lawrence originally grew up in New Zealand and Multi-tooth Extrusion Attachments). The The patient presented with a Class III, graduated from the University of Otago, New Zealand with appliance also helped to precisely correct a bachelor’s degree in Dental Surgery (with honours). Upon open-bite malocclusion with an underlying graduation, Dr Lawrence worked in private and hospital the anterior-posterior dimension by mandibular asymmetry. This case could practice as a General Dentist. She spent 2 years in the United keeping the lower incisors retroclined and Kingdom as a Senior House Officer in Oral and Maxillofacial be treated with orthognathic surgery to proclining the upper incisors. The addition Surgery. Returning to Australia, Dr Lawrence completed her improve the retrusive maxilla and mandibular 3-year specialist orthodontic training at the University of of the Class III elastics in combination with asymmetry; however, it was effectively Melbourne, Australia. Dr Lawrence has previously worked at IPR also aided in the correction of the the Royal Children’s Hospital, Melbourne in the Craniofacial treated with the Invisalign appliance alone. lower midline discrepancy. Unit. She is in private orthodontic practice in partnership Optimised Multi-plane Extrusion Attachments with her husband, Dr Igor Lavrin. She is a Clinical Tutor • Upon review of the case, to improve for postgraduate orthodontic students at the University of were used to effectively extrude the upper Melbourne. She has a keen interest in Invisalign treatment efficiencies in treatment, I would add more anterior teeth, which improved the overbite and has been using the Invisalign appliance for over 10 proclination to the upper incisors in the and also created a more harmonious smile years. Dr Lawrence co-presented at the 2015 ANZ Invisalign Orthodontic Forum, Queenstown, New Zealand. She was also initial aligner phase. Often when correcting line. Elastics were utilised during treatment to a co-speaker for Orthodontic Invisalign Masterclasses in ANZ a Class III malocclusion, if the torque of the help with Class III correction and to improve and is a current Future Elite NZ speaker for 2016.