WWW.DENTALLEARNING.NET VOLUME 6 | ISSUE 3, June 2018 DENTAL LEARNING A PEER REVIEWED PUBLICATION Knowledge for Clinical Practice

Clear Aligner Therapy and the Orthodontic-Restorative Interface by Jeffrey R. Briney, DDS

Single Crown Restoration

INSIDE After Trauma Earn 2 CE Christopher Hooper, DDS Credits

Written for dentists, hygienists and assistants DENTAL LEARNING

Clear Aligner Therapy and the Orthodontic-Restorative Interface

ABSTRACT EDUCATIONAL OBJECTIVES

Clear aligner therapy improves esthetics during orthodontic The overall goal of this course is to provide information on clear care in comparison to fi xed orthodontic appliances and standard aligner therapy and its application in enhancing restorative out- removable appliances. In part due to this, the number of adults comes and treating crowding. After completing this article, the seeking orthodontic treatment has increased, and clear aligner reader will be able to: therapy is now frequently performed on adults and adolescents. The availability of auxiliaries/composite attachments has also 1. Describe the types of movements that can be achieved using improved the level of control and types of tooth movements that . can be attained using clear aligners. In addition, there is less risk 2. Review the digital workfl ow for clear aligner therapy. of gingivitis, caries, and oral irritations with clear aligner therapy 3. Defi ne the role of auxiliaries and describe how these are used than is associated with fi xed orthodontic appliance therapy. Clear for clear aligner therapy. aligner therapy involves a digital workfl ow for treatment planning, 4. Delineate the potential benefi ts of clear aligner therapy for and is also used to enhance restorative care by providing for space/ patients, including those requiring restorative care. repositioning teeth to improve potential results and/or minimize the invasiveness or extent of restorative care required to achieve the desired result, and may also reduce the duration of treatment.

ABOUT THE AUTHOR rthodontic treatment options include fi xed Jeffrey R. Briney, DDS – Dr. Briney is an award-winning orthodontic appliances (FOA), traditional removable graduate of Indiana University and has a 20-year Oappliances, and clear aligners. The genesis of clear history of private practices in Dana Point and Laguna aligners began in 1944 with the use of thermoplastic full Beach, CA, which have been featured in many dental tooth-coverage appliances to obtain tooth movement.1 FOA publications. He is currently establishing a collection continue to be the most frequent method of treatment. More of practices in Dubai, which will debut in late 2018. He speaks adults are seeking orthodontic treatment, and the number regularly around the world with regard to his personal approach and proportion of cases treated with clear aligners has to Surgical, Laser & Restorative Dentistry, complemented with steadily increased over the past two decades. This can be Facial Esthetics & . Dr. Briney also writes for several attributed to the perceived importance of esthetics and the publications ranging from techniques utilized in his personal cases availability of clear aligners, which have improved patient to evaluating many dental products that are new to our dental comfort and esthetics during orthodontic treatment. Clear fi eld. He currently teaches around the world for Biolase, Coltene, aligner systems are available direct-to-consumer without ClearCorrect, Straumann, and Suni Imaging. Dr. Briney teaches live dentist/orthodontist supervision. The focus of this article is webinars for cerecdoctors.com. His passion in dentistry is centered on clear aligners that are supervised by dentists and around his mission work in Haiti. Dr. Briney can be reached at orthodontists, and designed to deliver results for simple and [email protected] or through his website at www.drbriney.com. complex cases while maintaining oral health.

SPONSOR/PROVIDER: This is a Dental Learning, LLC continuing education activity. COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from ClearCorrect. DESIGNATION STATE- MENTS: Dental Learning, LLC is an ADA CERP recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Dental Learning, LLC designates this activity for 2 CE credits. Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 2/1/2016 - 1/31/2020. Provider ID: # 346890. EDUCATIONAL METHODS: This course is a self-instructional journal and web activity. Information shared in this course is based on current information and evidence. REGISTRATION: The cost of this CE course is $29.00 for 2 CE credits. PUBLICATION DATE: June 2018. EXPIRA- TION DATE: May 2021. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 2 CE credits for this educational activity, participants must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. AUTHENTICITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEGRITY STATEMENT: Information shared in this continuing education activity is developed from clinical research and represents the most current information available from evidence-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the eld related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership position or a commercial interest in any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course, Joseph Riley, does not have a leadership or commercial interest in any products or services discussed in this educational activity. He can be reached at [email protected]. TARGET AUDIENCE: This course was written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLATION/RE- FUND POLICY: Any participant who is not 100% satis ed with this course can request a full refund by contacting Dental Learning, LLC, in writing. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to [email protected]. Go Green, Go Online to www.dentallearning.net take your course.

Dental Learning, LLC is a Dental Board of California CE Provider. The California Provider # is RP5062. All of the infor- Approved PACE Program Provider mation contained on this certi cate is truthful and accurate. Integrated Media Solutions Inc./DentalLearning.net is an ADA CERP Recognized Provider. FAGD/MAGD Credit Completion of this course does not constitute authorization ADA CERP is a service of the American Dental Association to assist dental profession- Approval does not imply acceptance by for the attendee to perform any services that he or she is not als in identifying quality providers of continuing dental education. ADA CERP does not legally authorized to perform based on his or her license or approve or endorse individual courses or instructors, nor does it imply acceptance of a state or provincial board of dentistry or AGD endorsement. permit type. This course meets the Dental Board of Califor- credit hours by boards of dentistry. Concerns or complaints about a CE provider may be nia’s requirements for 2 units of continuing education. CA directed to the provider or to ADA CERP at www.ada.org/cerp. Integrated Media Solutions 1/31/2016 - 2/1/2020 course code is 02-5062-18011. Inc./DentalLearning.net designates this activity for 2 continuing education credits. Provider ID: # 346890 AGD Subject Code: 370, 377 Clear Aligner Therapy and the Orthodontic-Restorative Interface

Clear Aligner Therapy to traditional models.6,7 The treatment plan set-up, projected Clear aligner therapy has transformed orthodontic tooth movements and series of aligners are then reviewed treatment. While initially used with some success for simple by the dentist/orthodontist and patient. After acceptance, cases, sequential series of clear aligners are now used to 3D-printed models are created and the aligners fabricated. The treat anterior crowding; midline discrepancies; Class I, II, series of aligners is then sent to the offi ce. Should extensive and III ; and to open and close spaces.2–4 Tooth tooth movement be required, interim scans can be planned and movements performed include tipping, rotation/derotation, taken partway through treatment and the workfl ow repeated torquing, , extrusion, and anterior-posterior for the subsequent aligners required to complete treatment. translation.2–5 The combination of planned tooth movements When looking at clear aligner systems, considerations include will result in planned arch changes, whether distalization, compatibility with browsers, devices, and whether and which mesialization, lingualization, or arch expansion. types of digital scans may be submitted. Other considerations include the ability to adapt treatment plans, and the overall support provided by the company. Digital Workfl ow Computer-aided design/computer-aided manufacturing (CAD/CAM) is integral to clear aligner systems. Digital scans are Auxiliaries taken of both arches as well as digital images (photographs) of Auxiliaries include resin engagers/buttons/attachments the patient’s dentition, which typically includes front views, left that are bonded to selected teeth. In addition, expanders and right lateral views, upper and lower occlusal views, profi le, can be used to effect expansion of space between teeth. and full-face "smiling" and "not smiling" images. Intraoral images Auxiliaries allow for more diffi cult tooth movement than should be taken using cheek retractors and for the occlusal would be otherwise possible,8 provide greater control over views also using intraoral mirrors. The scans and images are tooth movement, and/or are used to improve aligner reten- then uploaded in minutes to a designated site, where the digital tion.1 The need for, and type of, auxiliaries is typically deter- models and treatment plan setup are designed. With some mined chairside and then treatment-planned in the setup. systems, conventional impressions can be taken instead of Depending on the system, pressure points within aligners digital scans and sent to a designated location to be scanned. can also be used to generate force.1 Engagers can be used Intraoral scans are easier for patients and the clinician/assistant, to attach for traction to distalize upper posterior and digital models are at least as or more accurate and reliable teeth when treating Class II cases, or the elastics can be at- for measurements made during treatment planning compared tached to slits/cutouts in the aligner. Temporary

Digital scans Creates Dentist/orthodontist 3-D model virtual approves (or Upload to printed; models; requests changes to) Radiographs software aligners treatment setup, auxiliaries, and clinical fabricated plan setup aligner series images

Figure 1—Digital work ow for clear aligners

Copyright 2018 by Dental Learning, LLC. No part of this publication may be reproduced or transmitted in any form without prewritten CE Editor Creative Director permission from the publisher. FIONA M. COLLINS MICHAEL HUBERT Managing Editor Art Director JUNE 2018 DENTAL LEARNING BRIAN DONAHUE JOE CAPUTO 3 500 Craig Road, Floor One, Manalapan, NJ 07726 DENTAL LEARNING

devices (TADs) can also be combined with clear aligner use to control and achieve planned tooth movement.9

Interproximal Reduction (IPR) can be performed to create a small or moderate amount of additional space if needed, by removing proximal enamel prior to taking digital scans and images.9,10 This may avoid orthodontic extractions, which are more invasive. IPR can be performed manually (using interproximal strips or hand discs) or mechanically (using diamonds or carbides in a handpiece), and care must be taken to avoid removing too much enamel, miscontouring teeth, or damaging soft tissues. Figure 2a—Initial facial view showing 4-mm midline discrepancy The Orthodontic–Restorative Interface Orthodontic treatment with clear aligners provides oppor- tunities to enhance restorative care and allows treatment that would otherwise not be possible, take longer, be more invasive, or result in less desirable results. Examples of the application of clear aligner therapy prior to restorative care include creat- ing space for restorations, closing spaces, derotating anterior teeth so that they can be restored without esthetic or functional compromises, and adjusting the position of teeth to enhance the planned fi nal restorative outcome. Since clear aligners are intended to be worn all day and night except when eating or performing oral hygiene, and are removable appliances, the Figure 2b—Right lateral view patient’s level of commitment and anticipated compliance with aligner use must be assessed prior to embarking on treatment. The two cases below both address clear aligner therapy using ClearCorrect technology for two different indications.

Case No. 1 The patient in this case is a 30-year-old healthy male whose chief complaint was "the spaces between his up- per front teeth" along with "crowding in his lower front teeth." His past dental history, clinical examination and panoramic radiograph revealed a caries-free dentition, no periodontal disease, and no missing teeth other than Figure 2c—Left lateral view a congenitally missing upper right lateral incisor and his

4 VOLUME 6 | ISSUE 3 Clear Aligner Therapy and the Orthodontic-Restorative Interface

Figure 2d—Upper occlusal view Figure 3—Initial panoramic radiograph

supported crown in the newly created space, and cosmetic restorative treatment for the abfractions. The estimated treatment time was 9 months for clear aligner therapy followed by 3 months for implant, restorative, and cosmetic treatment, for a combined 1-year start-to- fi nish treatment plan. A clear would be required afterward to prevent relapse in the lower arch. Digital scans and images were taken, and uploaded to ClearCorrect's site. Two distinct series of aligners were Figure 2e—Lower occlusal view planned, which would allow the addition of a pontic as an interim solution until more space had been created. The initial treatment plan setup was created and the fi rst aligner 3rd molars, which had been removed 10 years previously. series planned (Figure 4). After reviewing with the patient He presented with multiple abfractions associated with and agreeing on the plan, the aligners were fabricated and his occlusion and parafunction, and a 4-mm midline shift sent to us. By 6 months, the patient had worn 12 sequential (Figures 2, 3). The patient had never received orthodontic sets of clear aligners. Signifi cant space had been created, treatment. He had recently received two consultations for future implant placement in the upper right lateral incisor and opinions on treatment for his chief complaint, and position, crowding in the lower anterior region almost elimi- came to my offi ce to obtain a third opinion. As always, I nated, and the midline shift signifi cantly reduced (Figure 5). discussed all options with the patient without fi rst look- New scans and images were taken at 6 months for the ing at the other opinions. After discussion, the patient remaining aligners, with a virtual pontic included in the setup decided on the recommended treatment. for viewing and approval. Aligner #13 also included the use Treatment would involve clear aligner therapy to of engagers (marked in blue in the setup) that would help to create space and a functional arch form. This would control and enhance tooth movement (Figure 6). We viewed be followed by placement of an implant and implant- the setup, and after approving it without any adjustments,

JUNE 2018 5 DENTAL LEARNING

Figure 4a—Initial setup for clear aligner fabrication Figure 5a—Status at 6 months

Figure 4b—Upper arch setup Figure 5b—Occlusal view at 6 months

the remaining aligners were fabricated with voids for the engagers at the sites for teeth #4, 11, 21, 22, and 27. To create the engagers, the enamel was acid-etched at the precise location where the engagers would be placed, rinsed off, and dried, then bonding agent was applied and light-cured. After applying petroleum jelly as a separator inside the voids within the aligners, two-thirds of the depth of the voids for engagers were fi lled with universal composite, and the remaining third that would be against the tooth was fi lled with fl owable composite (Figure 7). Figure 4c—Lower arch setup By 9 months, suffi cient space had been created to place an implant and crown, the midlines matched, and the lower

6 VOLUME 6 | ISSUE 3 Clear Aligner Therapy and the Orthodontic-Restorative Interface

Figure 6—Setup with virtual pontic and engagers Figure 8b—Upper arch at 9 months with adequate space for an implant

Figure 7—Aligner with composite pontic and engagers Figure 9—Comparison of space pre- and post-treatment with clear aligners showing the pontic within the clear aligner in the image on the right

Figure 8a—Stable presentation for the upper teeth prior to implant placement. Mid-course therapy with additional aligners continued for the lower teeth during the healing Figure 10—Implant placed at site #7 stage of the implant.

JUNE 2018 7 DENTAL LEARNING

Figure 13a—Before treatment Figure 11—Panoramic radiograph showing ideal implant position

Figure 12—Status at the postoperative visit at 1 week Figure 13b—Status at the postoperative visit at 1 week anterior teeth were no longer crowded (Figures 8, 9). At 9 Case No. 2 months, a surgical guide was fabricated. During the course This is my "Dubai/9500 mile case." After I had just returned of the implant placement and subsequent healing phase, the from a mission in Haiti, a walk-in patient who was 12 years- lower teeth had a continued course of clear aligner therapy of-age from Dubai came into my offi ce with her father while for 5 more aligners and the upper teeth were maintained with they were vacationing, after she had begged him at home nonactive aligners with an incorporated pontic. The implant for clear aligners and he had promised that he would let her was placed 1 month later, followed by a 1-week postopera- have them. The problem was that they were leaving 4 days tive visit and uneventful healing. The custom abutment and later to return home. She presented with a of the temporary crown were placed 2 months later (Figures 10–12). upper right lateral incisor, and crowding of the upper and The patient also wanted to have his teeth whitened, for lower dentition. (Figure 14) After an evaluation and radio- which we used a laser, and esthetic bonded composites were graphs, a long debate, and a call to the company to describe placed over the abfractions. The patient was delighted with my dilemma (time, diffi cult case, long distance), we decided the result (Figure 13). to proceed with digital scans at this appointment. Within 4

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Figure 14a—Initial facial view Figure 14c—Initial view with teeth occluded, showing crossbite

Figure 14b—Initial occlusal view Figure 15—Initial treatment plan setup days we had taken digital scans and images, reviewed and ap- Discussion proved the treatment plan setup for correction of her crowding The above cases highlight different aspects of clear and crossbite, the aligners had been shipped to us overnight, aligner therapy. The patient in the fi rst case had previously and the fi rst aligner set and engagers were placed (Figure 15). received two different opinions. The fi rst clinician gave one This young lady smiled from ear to ear now that she had her option, with an estimated time of 4 to 6 weeks. It was for clear aligners. After returning home, she continued to wear her full-coverage crowns for the maxillary anteriors to make aligners, swapping them out at the agreed times and staying tooth #6 look like a lateral incisor and #5 like a canine, and in touch remotely. I visited Dubai at the 6-month follow-up, and veneers for the lower anterior teeth. The second opinion took digital scans and images for the next series of aligners. At recommended FOA for a period of about 2 years, followed 6 months, the crossbite was resolved and only minor crowding by an implant-supported restoration at site #7 and veneers and adjustments were still needed. Treatment continues and for the upper anterior teeth. The patient had been told that should be completed in the next 2 months. The already dramatic clear aligners were not suitable. An approach similar to the change has delighted this patient and her father (Figures 16, 17). fi rst opinion would have been considered for the fi rst case if

JUNE 2018 9 DENTAL LEARNING

Figure 16a—Facial view at 6 months Figure 17a—New setup at 6 months for aligner #13

Figure 16b—Lateral view in occlusion at 6 months Figure 17b—New setup with engager positions the patient had refused our fi rst recommendation for clear series of aligners made treatment possible despite aligners. In the end, clear aligner therapy combined with geographic limitations. Unlike emergencies resulting conservative restorative treatment produced an excel- from breakage of wires or debonding of brackets,12 lent result and a happy patient. It is worth mentioning that there are also few emergencies with clear aligners and studies on clear aligners have been conducted since the if a replacement aligner is needed due to the original late 1990s and conclusions based on the studies available, being misplaced/lost, this is easily resolved using spanning a number of years.11 Studies showed that some existing digital images. This is a signifi cant benefi t tooth movements were diffi cult to achieve, or that pre- for patients, avoids potential irritation as well as dicted vs actual results differed although clinically accept- inconvenience, and no additional chair time is required. able. However, signifi cant advances have occurred in clear It can also be benefi cial in cases where treatment visits aligner therapy in the last fi ve years, including the use of are intermittent and treatment is otherwise remote. precise, treatment-planned auxiliaries that better control Better oral hygiene with less plaque and gingivitis is gener- and promote planned tooth movement and the addition of ally observed in patients wearing clear aligners vs FOA.13,14 A newer systems. clear aligner does not create a plaque trap, can be removed In the second case, the ability to remotely steer prior to oral hygiene, and can be cleaned while outside the treatment, and for the patient to continue with her mouth. Orthodontic decalcifi cations are an additional and

10 VOLUME 6 | ISSUE 3 Clear Aligner Therapy and the Orthodontic-Restorative Interface

signifi cant concern for patients wearing FOA,15 but not for pa- as shown here. Clear aligners also offer an effective, tients wearing clear aligners. Patients also report signifi cantly conservative, and relatively quick method to enhance less discomfort with clear aligners than with FOA.16 esthetic and functional outcomes in restorative care.

Practice Building References Adults have driven the increased demand for clear align- 1. Weir T. Clear aligners in orthodontic treatment. Aust Dent J. 2017;62 Suppl 1:58-62. ers and adapt easily to them without a signifi cant impact on 2. Rossini G, Parrini S, Castro orio T, et al. Ef cacy of clear aligners in con- self-esteem.17 Children and adolescents 8 to 17 years of age have trolling orthodontic tooth movement: a systematic review. Angle Orthod. 2015;85(5):881-9. also indicated a preference for clear aligners over FOA and other 3. Li W, Wang S, Zhang Y. The effectiveness of the Invisalign appliance in extrac- appliances.18 In comparison to other orthodontic treatment op- tion cases using the ABO model grading system: a multicenter randomized controlled trial. Int J Clin Exp Med. 2015;8(5):8276-82. tions, clear aligners were rated signifi cantly higher on attractive- 4. Boyd RL. Complex orthodontic treatment using a new protocol for the Invis- ness and acceptability in another survey, and this correlated with align appliance. J Clin Orthod. 2007;41(9):525-47. patients being willing to pay more for them.19 Being able to take 5. ClearCorrect. Parameters for Selecting a Case. Available at: https://support. clearcorrect.com/hc/en-us/articles/206676997-Parameters-for-Selecting-a- digital scans and clinical images is comfortable for patients, and Case#types. rapid turnaround and access through a doctor portal makes it 6. Goonewardene RW, Goonewardene MS, Razza JM, Murray K. Accuracy and validity of space analysis and irregularity index measurements using digital possible to show patients the proposed end result on the screen models. Aust Orthod J. 2008;24(2):83-90. and go over what steps would be needed. This is helpful for 7. Luu NS, Nikolcheva LG, Retrouvey JM, et al. Linear measurements using virtual study models. Angle Orthod. 2012;82(6):1098-106. case acceptance and as a practice builder. Treatment with clear 8. Engagers. Available at: https://support.clearcorrect.com/hc/en-us/ aligners also requires less chairside time and shorter treatment articles/203836198-Engagers-aka-Attachments-. times than FOA for mild to moderately complex cases.20 Few 9. Lin JC, Tsai SJ, Liou EJ, Bowman SJ. Treatment of challenging malocclusions with Invisalign and miniscrew anchorage. J Clin Orthod. 2014;48(1):23-36. patients report they would not have undergone clear aligner 10. Zachrisson BU, Nuoygaard L, Mobarak K. Dental health assessed more than therapy after experiencing it, and in one study 98% would still 10 years after interproximal enamel reduction of mandibular anterior teeth. Am J Orthod Dentofacial Orthop. 2007;131:162-9. have done so compared to 78% for FOA.16 11. Tepedino M, Paoloni V, Cozza P, Chimenti C. Movement of anterior teeth Experienced clinicians can use clear aligners to treat the using clear aligners: a three-dimensional, retrospective evaluation. Prog Orthod. 2018;19(1):9. deciduous and permanent dentitions. Although clear aligner 12. Dowsing P, Murray A, Sandler J. Emergencies in orthodontics. Part 1: Man- therapy can be used for dental expansion, skeletal expansion agement of general orthodontic problems as well as common problems with is best treated using standard orthodontic treatment with  xed appliances. Dent Update. 2015;42(2):131-4,137-40. 13. Abbate GM, Caria MP, Montanari P, et al. Periodontal health in teenagers expanders. It is important to check whether the patient is be- treated with removable aligners and  xed orthodontic appliances. J Orofac ing compliant with wearing the aligners 22 hours per day. The Orthop. 2015;76(3):240-50. 14. Lu H, Tang H, Zhou T, Kang N. Assessment of the periodontal health status in fi rst telltale sign that a patient is non-compliant is when he/she patients undergoing orthodontic treatment with  xed appliances and Invisalign arrives not wearing the aligner. Sending out text blasts remind- system: A meta-analysis. Medicine (Baltimore). 2018;97(13):e0248. 15. Juliena KC, Buschang PH, Campbell PM. Prevalence of white spot lesion ing aligner patients that they should be wearing them helps by formation during orthodontic treatment. Angle Orthod. 2013;83(4):641-7. regularly reminding them. 16. Azaripour A, Weusmann J, Mahmoodi B, et al. Braces versus Invisalign®): gingival parameters and patients' satisfaction during treatment: a cross-sectional study. BMC Oral Health. 2015;15:69. Conclusions 17. Cooper-Kazaz R, Ivgi I, Canetti L, et al. The impact of personality on adult pa- Clear aligners have truly transformed orthodontic tients' adjustability to orthodontic appliances. Angle Orthod. 2013;83(1):76-82. 18. Walton DK, Fields HW, Johnston WM, et al. Orthodontic appliance treatment and made it more accessible and more preferences of children and adolescents. Am J Orthod Dentofacial Orthop. desirable to adults and teenagers. Starting with simple 2010;138(6):698.e1-12; discussion 698-9. 19. Rosvall MD, Fields HW, Ziuchkovski J, et al. Attractiveness, acceptabil- cases builds experience before graduating to more ity, and value of orthodontic appliances. Am J Orthod Dentofacial Orthop. complex cases, and good support is essential. With 2009;135(3):276.e1-12; discussion 276-7. proper treatment planning, excellent results can be 20. Zheng M, Liu R, Ni Z, Yu Z. Ef ciency, effectiveness and treatment stability of clear aligners: A systematic review and meta-analysis. Orthod Craniofac Res. obtained even when treatment is partially remote 2017;20(3):127-33.

JUNE 2018 11 DENTAL LEARNING Clear Aligner Therapy and the Orthodontic-Restorative Interface

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1. ______is a reason given for the increase in the 6. For complex cases, it is essential that all scans are taken number and proportion of orthodontic cases treated at the start of treatment to avoid having to repeat with clear aligners. the workflow. a. The perceived importance of function a. True b. The perceived importance of occlusion b. False c. Improved esthetics during treatment d. All of the above 7. Auxiliaries ______. a. allow for more difficult tooth movement but reduce 2. The genesis of clear aligner therapy began in aligner retention ______with the use of thermoplastic full b. are created on the outer aspect of the aligner tooth-coverage appliances. c. are created by 3-D printing, then attached to a. 1924 the tooth b. 1944 d. provide greater control over tooth movement c. 1964 d. 1984 8. The need for, and type of, auxiliaries is determined ______. 3. Class II malocclusions can be treated with clear aligners. a. by the software program a. True b. by the laboratory technician b. False c. chairside d. by the patient 4. Intraoral images that are of the occlusal view should be taken using ______. 9. Engagers can be used to attach ______for traction a. cheek retractors and a saliva ejector to distalize upper posterior teeth. b. cheek retractors and intraoral mirrors a. wires c. cheek retractors, a saliva ejector, and intraoral mirrors b. elastics d. cheek retractors, occlusal markers, and intraoral c. screws mirrors d. all of the above

5. Compared to traditional impressions, intraoral digital 10. Interproximal reduction can be performed to ______. scans ______. a. remove proximal enamel a. are easier for patients b. avoid orthodontic extractions b. are easier for clinicians c. create a small to moderate amount of space c. result in digital models that are at least as accurate as d. all of the above traditional models d. all of the above

12 VOLUME 6 | ISSUE 3 CEQuiz

16. Children and adolescents 8 to 17 years of age have 11. Clear aligner therapy prior to restorative care can be indicated a preference for fi xed orthodontic appliances performed to ______. with multicolored brackets over clear aligners. a. shorten teeth a. True b. close or open spaces b. False c. orthodontically extract teeth d. improve the shape of adjacent teeth 17. If an aligner needs to be replaced due to misplacement or loss, ______. 12. The patient’s level of commitment and anticipated a. existing digital images can be used compliance with aligner use must be assessed prior to b. treatment is delayed by a month embarking on treatment, because ______. c. new scans must always be taken a. treatment is shorter than with FOAs d. make sure to charge the patient for it b. the aligners will only be worn for 12 hours a day c. the aligners must be worn even when the patient 18. Orthodontic decalcifi cations are ______. is eating a. not a signifi cant concern for patients wearing d. the aligners should be worn almost all day and night FOA b. a barrier to clear aligner therapy 13. A clear retainer is used after clear aligners to ______. c. not a signifi cant concern for patients wearing a. prevent arch relapse clear aligners b. fi ne-tune tooth movement d. a signifi cant concern whether the patient is c. treat bruxism wearing an FOA or a clear aligner d. treat sleep apnea 19. In one survey, clear aligners were ______other 14. While extra space is being created for an implant, a orthodontic treatment options. pontic can be fabricated inside the aligner to fi ll the a. perceived to be more bulky than existing amount of space. b. rated signifi cantly lower for compliance than a. True c. rated signifi cantly higher on acceptability than b. False d. perceived to be too thin compared to

15. In order to prevent composite from adhering to the 20. Clear aligners can offer an effective, conservative, inside of aligners while engagers are being created, and relatively quick method to enhance esthetic and ______should be applied as a separator. functional outcomes in restorative care. a. acid etch a. True b. petroleum jelly b. False c. gel activator d. temporary cement

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*E-mail: AGD Code: 370, 377 *Telephone: License Renewal Date: EDUCATIONAL OBJECTIVES QUIZ ANSWERS 1. Describe the types of movements that can be achieved using clear aligners. Fill in the circle of the appropriate 2. Review the digital workfl ow for clear aligner therapy. answer that corresponds to the 3. Defi ne the role of auxiliaries and describe how these are used for clear aligner therapy. question on previous pages. 4. Delineate the potential benefi ts of clear aligner therapy for patients, including those requiring restorative care. 1. A B C D COURSE EVALUATION 2. A B C D Please evaluate this course using a scale of 3 to 1, where 3 is excellent and 1 is poor. 3. A B C D 1. Clarity of objectives ...... 3 2 1 4. A B C D 2. Usefulness of content ...... 3 2 1 5. A B C D 3. Bene t to your clinical practice ...... 3 2 1 6. A B C D 4. Usefulness of the references ...... 3 2 1 7. A B C D 5. Quality of written presentation ...... 3 2 1 8. A B C D 6. Quality of illustrations ...... 3 2 1 9. A B C D 7. Clarity of quiz questions ...... 3 2 1 10. A B C D 8. Relevance of quiz questions ...... 3 2 1 11. A B C D 9. Rate your overall satisfaction with this course ...... 3 2 1 12. A B C D 10. Did this lesson achieve its educational objectives? Yes No 13. A B C D 11. Are there any other topics you would like to see presented 14. A B C D in the future? ______15. A B C D ______16. A B C D 17. A B C D COURSE SUBMISSION: Dental Learning, LLC A B C D 1. Read the entire course. 500 Craig Road, First Floor 18. 2. Complete this entire answer sheet in Manalapan, NJ 07726 19. A B C D either pen or pencil. *If paying by credit card, please note: 20. A B C D 3. Mark only one answer for each question. MasterCard | Visa | AmEx | Discover 4. Mail answer form or fax to 732-303-0555. *Account Number Price: $29 CE Credits: 2 For immediate results: ______Save time and the environment 1. Read the entire course. *Expiration Date 2. Go to http://dentallearning.net/CAT-ce by taking this course online. 3. Log in to your account or register to create an ______account. The charge will appear as Dental Learning, LLC. If you have any questions, 4. Complete course and submit for grading to receive your CE veri cation certi cate. If paying by check, make check payable to please email Dental Learning at Dental Learning, LLC. [email protected] A score of 70% will earn your credits. ALL FIELDS MARKED WITH AN ASTERISK (*) ARE REQUIRED or call 888-724-5230. PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to [email protected]. COURSE EVALUATION and PARTICIPANT FEEDBACK: We encourage participant feedback pertaining to all courses. Please be sure to complete the evaluation included with the course. INSTRUCTIONS: All questions have only one answer. Participants will receive con rmation of passing by receipt of a veri cation certi cate. Veri cation certi cates will be processed within two weeks after submitting a completed examination. EDUCATIONAL DISCLAIMER: The content in this course is derived from current information and research based evidence. Any opinions of ef cacy or perceived value of any products mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily re ect those of Dental Learning. Completing a single continuing education course does not provide enough information to make the participant an expert in the  eld related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST: All participants scoring at least 70% on the examination will receive a CE veri cation certi cate. Dental Learning, LLC is an ADA CERP recognized provider. Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Please contact Dental Learning, LLC for current terms of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. Dental Learning, LLC is a California Provider. The California Provider number is RP5062. The cost for courses ranges from $19.00 to $90.00. RECORD KEEPING: Dental Learning, LLC maintains records of your successful completion of any exam. Please contact our of ces for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within  ve business days of request. Dental Learning, LLC maintains veri cation records for a minimum of seven years. CANCELLATION/REFUND POLICY: Any participant who is not 100% satis ed with this course can request a full refund by contacting Dental Learning, LLC in writing or by calling 1-888-724-5230. Go Green, Go Online to www.dentallearning.net to take this course. © 2018

14 VOLUME 6 | ISSUE 3 Single Crown Restoration After Trauma Christopher Hooper, DDS

19-year-old female presented in my offi ce with dental trauma. While at a party, she became intoxicated, A passed out, and hit her front tooth on a beer keg. She had then received emergency treatment elsewhere. The patient presented in my offi ce with pulpal extirpation, partial crown lengthening, and a temporary crown. After removing the temporary crown, we found a knife- edge margin that was completely violating biologic width, even after partial crown lengthening by a local periodontist. We completed the endodontic treatment, placed a titanium post (Brasseler USA) and a core buildup was fabricated using bonded resin-based composite. I then revised the preparation Figure 2—Preoperative view of the preparation. with a chamfer, bringing it coronally out of the biologic space. The previously created knife-edge prep was left uncovered, hoping for new attachment or reattachment, which ultimately did occur. Photos and hand sketches were sent to the lab detailing the restoration. A zirconia-based crown was ordered to create some masking, as well as lifelike translucency. The fi nal crown was cemented with RelyX luting cement (3M ESPE). After just 3 weeks, the periodontium responded beautifully. In addition, the fi nal contour, hue, and value of the single crown Figure 3—Note the signi cant infringement into the biologic width. are virtually fl awless. The chroma, however, is a bit too intense in the cervical third. The patient and her family were very pleased with the result, especially after only 3 weeks. Unfortunately, I was only able to the follow the patient for about 1 year, after which she relapsed into drug use and ultimately was incarcerated. This case exemplifi es how even the most challenging patients with diffi cult circumstances deserve our care, compassion, and very best efforts.

Figure 4—Postoperative wide view. Note the excellent gingival response and nice resulting crown.

Figure 1—Preoperative presentation with an acrylic temporary fabricated by another clinician.

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