INTRODUCTION TO CONCEPTS AND

PRINCIPLES OF CLEAR ALIGNER

TREATMENT

The objective is to gain a thorough understanding of how to manage cases

effectively, interpret provider instructions accurately, and make well-
informed decisions regarding treatment planning.
RATIONALE OF ORTHODONTIC ALIGNERS TREATMENT
CLASSIFICATION OF MALOCLLUSION
COMPARISON BETWEEN EDGEWISE APPLIANCES AND CLEAR ALIGNERS
CASE SELECTION FOR CLEAR ALIGNERS
RESOLUTION OF CROWDING
DEEP BITE TREATMENT
ANTERIOR OPEN BITE TREATMENT
CLASS II TREATMENT
CLASS III TREATMENT
LOWER INCISOR EXTRACTION TREATMENT
PREMOLAR EXTRACTION TREATMENT

RATIONALE OF ORTHODONTIC ALIGNERS

Origins in Orthodontics: Orthodontics is over 2,000 years old, with early references from
Hippocrates and Aristotle about straightening teeth.

Etruscan Period (300–500 BC): Excavations from this period revealed human mandibles with
wire ligatures and bands used to splint teeth, showing early attempts at dental treatments for
alignment.
Fauchard’s Bandeau (1728): Pierre Fauchard, known as the “father of modern dentistry,”
introduced the bandeau, a horseshoe-shaped piece of metal designed to expand the dental
arch and align teeth. This device was ligated to the teeth with wire ligatures and helped in
straightening the teeth by expanding the arches.

Ribbon Arch Appliance (Early 1900s): Fixed appliances, known as "ribbon arch" appliances,
were made from gold bands that were placed around individual teeth, with brackets soldered
onto them. Archwires were secured using wire ligatures and pins. Soft, malleable metals like
gold and silver-nickel alloy were commonly used in these appliances.
Shift to Stainless Steel (1950s–1960s): In the mid-20th century, the expensive gold bands
were replaced with stainless steel bands. Full-arch banded appliances were the standard until
the 1960s when direct bonding techniques were introduced, allowing brackets to be directly
bonded to the enamel.

Direct Bonding and the Edgewise Appliance (1960s): The fixed edgewise appliance, also
known as the “zero-degree” appliance, became popular in the 1960s. This required the
orthodontist to manually bend the archwire in three dimensions: first-order (in-and-out),
second-order (tip), and third-order (torque) bends to achieve proper occlusion.

Straight-Wire Appliance (1970): Dr. Lawrence Andrews proposed incorporating the necessary
bends for in-and-out, tip, and torque directly into the bracket base or slot itself. This
innovation eliminated the need for manual adjustments to the archwire. The straight-wire
appliance became the new standard in fixed orthodontic appliances and remains widely used
today.

Lingual Braces (1975): Two orthodontists, one American and one Japanese, independently
developed lingual braces. These braces were placed on the inside (lingual) surfaces of teeth,
providing an aesthetic alternative for patients who preferred not to have visible brackets.
Over time, advancements in technology enabled the use of digital imaging to customize
bracket bases and archwires for lingual braces.
Aesthetic Brackets (1980s): Sapphire and ceramic brackets emerged as more aesthetic
alternatives to metal brackets. These materials blended better with the natural color of the
teeth, making them more attractive to patients seeking less noticeable orthodontic
treatment.

Clear Aligners:

1. Early Concepts (1945): The concept of clear aligners dates back to 1945 when Dr. H.D.
Kesling proposed the use of a clear, vacuum-formed appliance to move teeth for minor
corrections. The process involved manually repositioning teeth in wax and creating a
separate clear retainer for each stage of movement, making it a labor-intensive and time-
consuming method suitable only for minor adjustments.
2. Advancement of Clear Aligners (1997): A major breakthrough in clear aligner technology
occurred in 1997 when two graduate students from Stanford University applied 3D
computer imaging to orthodontics. This led to the creation of the first mass-produced,
customized clear aligner system, revolutionizing the field of orthodontics. The new
technology made clear aligners much more accessible and practical for widespread use
in orthodontic treatment.
3. Revolutionary Change in Orthodontics: The introduction of clear aligners represents a
transformational change in orthodontics. Unlike the gradual, incremental changes seen
with fixed appliances over the years, clear aligners offered a radical shift in the way
orthodontic treatment could be carried out, challenging conventional orthodontic
thinking.
4. Evolution of Clear Aligners (Post-1999): Early clear aligners were primarily used for
treating mild malocclusions, such as minor crowding or Class I cases, using interproximal
reduction to create space. Over time, clear aligners have evolved significantly, with
advancements in material science (such as new tripolymer plastics) and sophisticated
software algorithms that allow for more precise and effective movement of teeth.
5. Comprehensive Treatment with Clear Aligners: Initially, clear aligners were thought to be
limited to minor adjustments, but modern clear aligners can now handle a much wider
range of malocclusions, including complex cases that were once considered unsuitable
for aligner treatment. Sophisticated attachment systems and optimized treatment plans
make clear aligners a viable option for comprehensive orthodontic care.
6. Clear Aligners as a Technique, Not a Product: There is a common misconception that
clear aligners are just a "compromise" appliance, limited to minor cases. In reality, clear
aligner therapy is a comprehensive orthodontic technique, not merely a product. Modern
clear aligner systems are capable of addressing complex orthodontic needs with
precision and effectiveness.
7. The Future of Orthodontics: As clear aligner technology continues to evolve, it is
expected to play an increasingly important role in the future of orthodontics. More
systems are being developed globally, and the use of digital technology and custom-
designed appliances is shaping the future of orthodontic treatment.
classification of malocclusion
1. Angle’s Classification

Class I (Neutrocclusion): The mesiobuccal cusp of the upper first molar aligns with the
mesiobuccal groove of the lower first molar. Slight deviations (half a cusp width) are still
classified as Class I.

Class II (Distocclusion): The lower first molar’s mesiobuccal cusp is positioned distal to
the Class I position.

Class III (Mesiocclusion): The lower first molar’s mesiobuccal cusp is positioned mesial
to the Class I position.

2. British Standards Institute Classification

Focuses on incisor relationships, independent of molar position.

 Class I: Lower incisors occlude or are slightly below the cingulum plateau of the upper
central incisors.
Class II: Lower incisors are behind the cingulum plateau of the upper incisors, with two
subdivisions:
Division 1: Upper central incisors are proclined, with increased overjet.
Division 2: Upper central incisors are retroclined, with minimal or increased overjet.
Class III: Lower incisors are ahead of the cingulum plateau of the upper incisors,
resulting in reduced or reversed overjet.

Andrews' Six Keys

Not a classification system but a goal for achieving ideal occlusion. Andrews identified six
key features for a "normal" occlusion:

1. Molar relationship: the mesiobuccal cusp of the upper first molar occludes with the groove
between the mesiobuccal and middle buccal cusp of the lower first molar
2. Crown angulation: all tooth crowns are angulated mesially.
3. Crown inclination: incisors are inclined towards the buccal or labial surface.
4. Rotation.
5. Overbite.
6. Overjet.
Comparison Between Edgewise Appliances and Clear Aligners
Force, Engagement, and Anchorage

Force Application

Edgewise Appliances: Move teeth by pulling them. The archwire, when engaged in the
bracket, reverts to its original shape, pulling the tooth into the desired position.
Clear Aligners: Move teeth by pushing them. When the aligner is placed, it deforms
slightly over the teeth and pushes them into the desired position, aided by the elasticity
of the aligner material and optimized attachments.
Engagement

Edgewise Appliances: Teeth are engaged via an archwire ligated into the bracket slot. The
thicker and more rigid the archwire, the better the engagement and expression of tooth
movement.
Clear Aligners: Teeth are engaged by the aligner material wrapped around them. The
more surface area of the tooth covered by the aligner, the better the engagement.
Attachments can be added to increase surface contact and enhance tooth movement,
especially for teeth with small or irregular shapes.

Anchorage

Edgewise Appliances: Anchorage is typically reciprocal, meaning one segment of teeth

(e.g., posterior) provides anchorage for another segment (e.g., anterior). There can be
"loss of anchorage" when the posterior teeth move forward, which is managed during
treatment planning.
Clear Aligners: Anchorage can be predetermined and controlled at different stages. For
example, in sequential distalization, only specific teeth (e.g., second molars) move
initially, while others act as anchorage. Clear aligners offer precise control of anchorage,
as specific teeth can be made immovable at certain points in treatment.
Extrusion, Intrusion, Torque, and Root Inclinations

Extrusion:

Edgewise Appliances: Easy for single tooth extrusion but involves reciprocal movements
of adjacent teeth, such as when extruding a buccally erupted canine.
Clear Aligners: Extrusion is more challenging, especially for a single tooth. Auxiliary
devices like buttons or elastics may be needed. However, multi-tooth extrusion (e.g.,
maxillary incisors to close an anterior open bite) is achievable.
Intrusion:

Edgewise Appliances: Achieved using reverse-curved archwires, often causing unwanted

extrusion of posterior teeth. Segmental arches or auxiliary devices may be needed to
prevent this.
Clear Aligners: Allows precise selective or full-segment intrusion, with no unintended
extrusion. It provides excellent vertical control for leveling occlusal planes or correcting
deep bites.

Torque:

Edgewise Appliances: Torque is built into the bracket slot but can be limited by wire size
and slot play. Additional torque can be added with archwire bends.
Clear Aligners: Can provide lingual root torque via "power ridges" but also experiences
some "play," meaning less torque may be expressed than prescribed. Excessive torque
can be managed in certain cases, particularly in extraction cases.
Root Inclinations:

Edgewise Appliances: Root tip adjustments are made using bracket slot design and
archwire bends. However, "play" between the bracket and wire may reduce the control
over root inclinations.
Clear Aligners: Optimized root control through attachments and virtual gable bends
helps manage root inclinations more effectively, particularly in complex cases like incisor
or premolar extraction.
Treatment Mechanics

Incisor Inclination:

Edgewise Appliances: Tends to procline incisors during alignment.

Clear Aligners: Offers superior control over incisor inclination, allowing for the
prevention of proclination when desired

Vertical Control:

Edgewise Appliances: Overbite and overjet may decrease due to incisor proclination. This
is favorable for deep bites but unfavorable for cases with minimal overbite.
Clear Aligners: Provides excellent vertical control, ideal for cases with minimal overbite
or overjet, allowing for better leveling and alignment.

Midline Correction:

Edgewise Appliances: Requires compliance with anterior cross elastics, which can be
frustrating if midline correction fails.
Clear Aligners: Midline correction is more predictable and often involves interproximal
reduction, leading to a high likelihood of achieving midline correction as planned.

Tooth Size Discrepancy:

Edgewise Appliances: Tooth size discrepancies are adjusted midway through treatment,
usually by making compromises in space closure or occlusion.
Clear Aligners: The treatment-planning software calculates and resolves tooth size
discrepancies before treatment, offering choices such as interproximal reduction or
leaving space, based on the clinician’s preferences.
case selection for clear aligner treatment

Importance of Case Selection

Effective case selection is crucial for successful clear aligner treatment. Clinicians should
begin with simpler cases and progress to more complex ones as their experience grows. The
difficulty of a case is assessed by analyzing discrepancies in arch length, vertical, transverse,
and anteroposterior (AP) dimensions.

Arch Length Discrepancies

Mild crowding: Can be resolved with non-extraction options like expansion, proclination,
or interproximal reduction (IPR).
Moderate crowding: May require mandibular incisor extraction or arch distalization,
along with the above options.
Severe crowding: Typically requires premolar extractions combined with other
techniques (expansion, proclination, or IPR).
Treatment difficulty increases with the severity of crowding.

Vertical Discrepancies

Deep bite: Can be treated by proclining the maxillary and mandibular incisors (resulting
in relative intrusion), or by anterior intrusion and posterior extrusion. More complex
cases may require a combination of these methods.
Anterior open bite: Corrected by anterior extrusion and posterior intrusion. Severe cases
may need temporary anchorage devices (TADs) for posterior intrusion.
The complexity increases with the severity of the vertical skeletal discrepancy.

Transverse Discrepancies

Single-tooth crossbite: Easily treated with minor expansion or proclination.

Multiple-tooth crossbite: Requires more effort, with posterior expansion possible up to 2
mm per quadrant. Cross elastics may assist.
Skeletal crossbite: Requires rapid maxillary expansion (RME) or micro-implant-assisted
rapid maxillary expansion (MARPE) before clear aligners can be used.

Anteroposterior Discrepancies

Dental AP Discrepancies:
Small discrepancies (up to 2 mm) can be treated with posterior IPR or elastic wear.
Larger discrepancies (2–4 mm) may require sequential distalization or extractions.
Severe discrepancies (over 4 mm) may require extraction to correct the malocclusion.
Skeletal AP Discrepancies:
Class II (mandibular retrognathia): Clear aligners with mandibular advancement
features can address growing patients, while traditional growth modification methods
 (e.g., functional appliances) are used in the first phase, followed by clear aligners in
the second phase.
Class III (maxillary retrusion): Requires growth modification like rapid maxillary
expansion and face mask therapy before aligners can be used.
Nongrowing patients: May require dental camouflage or orthognathic surgery for
severe skeletal discrepancies.

Indications for Clear Aligner Treatment

Clear aligners are effective for a wide range of malocclusions, including simple and
moderately difficult cases. They are particularly effective in providing better vertical control
compared to traditional fixed appliances. However, the complexity of treatment increases
with the severity of the malocclusion. Advanced cases, such as severe skeletal discrepancies
or extraction cases, may require more experience with clear aligners.
RESOLUTION OF CROWDING

Clear aligner therapy often requires combining protocols to address arch length
discrepancies (crowding or spacing), vertical discrepancies (e.g., open bite, deep bite), and
anteroposterior (AP) discrepancies (e.g., Class II and Class III malocclusions).

Options for Resolving Arch Length Discrepancies

1. Crowding:
Arch Expansion: Broaden the dental arch.
Incisor Proclination: Move incisors forward.
Interproximal Reduction (IPR): Reduce tooth width between contacts.
Extractions

Spacing: Options to close spaces or maintain them in specific locations.

case 1
Mild Class II malocclusion with crowding

A 38-year-old woman presented with a mild Class II malocclusion with moderate

crowding in both dental arches and minimal overbite and overjet. Both the maxillary and
mandibular incisors were protrusive. The maxillary right first molar was missing, and
there was a fixed three-unit bridge in place. The maxillary left second molar was also
missing. The mandibular right first molar was replaced with a single-tooth implant.
Software Design

Key Considerations:

A fixed three-unit bridge in the upper right jaw and a dental implant in the lower right jaw
were kept stationary during treatment.
Posterior interproximal reduction (IPR) was done before the digital scan to accurately
reflect the space in the treatment plan.

Maxillary Arch (Upper Jaw):

IPR was performed near the first premolars.

The upper right canine was retracted into the IPR space to achieve a Class I canine
relationship.
On the upper left, molars and premolars were moved back (distalized) to create space for
aligning and retracting the front teeth.

Mandibular Arch (Lower Jaw):

 0.2 mm of IPR was performed between the lower incisors to align them without tipping
them forward.
Lower front teeth were slightly tipped backward (retroclined) and extruded to improve
the overbite.

1. Attachments for Tooth Movement:

Optimized Rotation Attachments: Placed on canines and premolars to assist with
their proper alignment.
Optimized Extrusive Attachments: Applied to the mandibular left central and lateral
incisors to aid in extrusion.
2. Precision Cuts:
Precision cuts for Class II elastics are positioned on the left buccal side to assist in
distalizing the teeth for achieving Class I canine and molar relationships.
3. Interproximal Reduction (IPR):
Specific amounts of IPR are incorporated into the treatment plan to create space and
facilitate proper alignment.

This design combines attachments, IPR, and elastics to effectively manage alignment and
occlusal correction.

1. Attachments for Tooth Movement:

 Optimized Rotation Attachments: Placed on canines and premolars to assist with
their proper alignment.
Optimized Extrusive Attachments: Applied to the mandibular left central and lateral
incisors to aid in extrusion.
2. Precision Cuts:
Precision cuts for Class II elastics are positioned on the left buccal side to assist in
distalizing the teeth for achieving Class I canine and molar relationships.
3. Interproximal Reduction (IPR):
Specific amounts of IPR are incorporated into the treatment plan to create space and
facilitate proper alignment.

This design combines attachments, IPR, and elastics to effectively manage alignment and
occlusal correction.

case 2
Mild Class II malocclusion with crowding

A 45-year-old man presented with a mild Class II malocclusion with minimal overbite and
moderate to severe crowding in both dental arches. There was severe incisal wear on the
maxillary incisors, and the maxillary left first molar was missing. In the mandible, there
were a number of lingual tori and lingually erupted second premolars.
The crowding would be resolved through a combination of maxillary and mandibular arch
expansion with IPR. The missing maxillary left first molar would be restored with a dental
implant after orthodontic treatment was completed.
Software Design

Maxillary Arch (Upper Jaw):

IPR (Interproximal Reduction): Done in the right quadrant to create space for aligning the
buccally erupted right canine.
Distalization: Premolars in the left quadrant were moved back to fill the space of a
missing first molar, creating room for the left canine and correcting the bite to a Class I
relationship.
Attachments: Optimized extrusive attachments were placed on the front teeth to
enhance the smile arc.
Pontic: A small pontic was placed at the site of the missing first molar, with open contacts
around it to improve aligner fit and control tooth/root movements.

Mandibular Arch (Lower Jaw):

Crowding Resolution: Combined arch expansion and anterior IPR were used to align the
teeth without changing the forward-backward position of the lower front teeth.
Tooth Staging: Teeth adjacent to the second premolars were moved first to create open
spaces, allowing for better alignment and uprighting of the second premolars.
DEEP BITE TREATMENT

Key Concepts

Intrusive Forces & Pressure Areas:

Problem: Intrusive forces from aligners may not be properly directed along the long axis
of the anterior teeth.
Solution: Adding pressure areas on the lingual surface of the aligner redirects forces
along the tooth’s long axis, improving effectiveness.

Optimized Deep Bite Attachments:

Passive Attachments: Placed on mandibular premolars to provide anchorage for anterior

intrusion.
Active Attachments: Deliver extrusive forces to mandibular premolars when needed to
control the bite.

Precision Bite Ramps:

These lingual prominences adjust throughout treatment to maintain tooth contact,

helping manage overjet and improve occlusion. They can’t coexist with pressure areas on
the maxillary incisors due to space constraints. Bite ramps can be placed on maxillary
canines if necessary.

Biomechanics for Deep Bite Correction:

Causes of deep bite may include upright/retroclined incisors, hypererupted maxillary

incisors, or a steep mandibular curve.
Treatment aims to procline or intrude incisors and selectively extrude premolars.
Skeletal pattern considerations are critical: in brachyfacial patients, premolar extrusion
may help, while in dolichofacial patients, anterior intrusion should be prioritized to avoid
posterior extrusion.

Anchorage for Anterior Intrusion:

When intrusive forces act on the anterior teeth, the posterior part of the aligner can lift.
To prevent this, attachments are added to premolars for anchorage to ensure the force
remains directed at the anterior teeth.

Staging in Treatment:

Proper staging ensures predictable results, especially with retroclined or hypererupted

incisors. The process typically follows this sequence:
 1. Procline
2. Intrude
3. Retract
Power ridges and bite ramps assist with lingual root torque during protraction.

Pressure Areas vs. Bite Ramps:

These features cannot be used on the same tooth simultaneously. Clinicians must choose
between using pressure areas on the maxillary incisors or bite ramps (often on canines if
overjet is present).

Overtreatment in Severe Cases:

In extreme deep bite cases (overbite >80%), overtreatment is necessary to create a

reverse curve of Spee and may include correcting the bite to 0 mm overbite, ensuring
long-term success.

CASE 1
Deep bite in Class I malocclusion

A 15-year-old adolescent boy presented with a Class I malocclusion with deep bite and minor

crowding . Both the maxillary and mandibular incisors were retroclined, and there was a
steep curve of Spee in the mandibular arch. The treatment plan involved intrusion and
proclination of the maxillary and mandibular incisors to correct the deep bite and resolve
any crowding as well as leveling of the curve of Spee.
SOFTWARE DESIGN

Bite ramps: Added to the palatal surface of the maxillary incisors.

Power ridges: Placed on mandibular incisors for proclination (forward movement).
Incisor intrusion: Planned for both arches to correct the deep bite.
Maxillary view: Shows bite ramps on the maxillary incisors.
Mandibular view: Shows mild labial (forward) movement of the mandibular incisors.
Premolar extrusion: Mild extrusion (less than 1mm) of mandibular first premolars to level
the curve of Spee.
CASE 2
Deep bite in Class II malocclusion

A 15-year-old adolescent boy presented with a Class II malocclusion with increased

overjet and constricted dental arches. The buccal occlusion was Class I on the right and
 Class II on the left. There was a deep bite with moderate crowding in the maxillary arch. A
steep curve of Spee was present in the mandibular arch. Arch expansion was planned for
both the maxilla and mandible to resolve the crowding. The treatment plan also involved
leveling the curve of Spee in the mandibular arch to correct the deep bite. The Class II
buccal relationship would be corrected with Class II elastics.

SOFTWARE DESIGN

Arch expansion: Both arches were expanded from a narrow V-shape to a broader U-
shape.
Superimpositions: Show the planned expansion, especially in the maxillary right and
mandibular right buccal quadrants.
Mandibular first premolars: Horizontal rectangular attachments were placed for
anchorage to level the curve of Spee.
Simulation jump: Added in the final stage to correct the buccal occlusion to Class I.
ANTERIOR OPEN BITE TREATMENT

Causes of Anterior Open Bite:

The causes are multifactorial, often involving myofunctional issues, but clear aligners
provide a strategy for correction without focusing on all potential causes.

Biomechanics for Correction:

Relative extrusion: Proclined incisors are retroclined to achieve extrusion.

Pure extrusion: Multi-tooth extrusive attachments are used for direct extrusion of
incisors.
Posterior intrusion: Maxillary and mandibular posterior teeth are intruded to help close
the open bite, often accompanied by upward and forward mandibular closure.

Skeletal Pattern Considerations:

Most effectively treated when:

The anterior open bite is dental, not skeletal.
Incisors are proclined and there is spacing.
The maxillary arch is narrow with lingually tipped posterior teeth.
Vertical skeletal patterns may require posterior intrusion (especially of maxillary molars)
to aid mandibular rotation and close the bite.

Anchorage:

When extrusive forces act on the anterior teeth, the posterior part of the aligner
experiences intrusive forces, helping to correct the open bite.
Attachments are required on the anterior teeth being extruded, but no attachments are
needed on posterior teeth for intrusion.

Staging:

In severe cases, posterior intrusionmay be staged in sequence:

Start with second molars, then move to first molars, and finally second premolars.
Attachments are placed on adjacent teeth to provide anchorage for the intrusion.

Overtreatment:

For long-term success, it’s recommended to finish treatment with heavy anterior
occlusal contacts and to overtreat the open bite correction, achieving at least 2 mm of
positive overbite in the final occlusion.

CASE 1
Anterior open bite in Class I malocclusion with midline deviation

A 14-year-old adolescent boy presented with a Class I malocclusion with a 3-mm anterior
open bite, an increased overjet of 4 mm, mandibular midline deviation, and a Class II
dolichofacial skeletal pattern with incisor protrusion. The treatment plan involved
correcting the anterior open bite by retroclining the maxillary and mandibular incisors
and intruding the posterior teeth. A request for maxillary anterior extrusion and posterior
intrusion was also included. Interproximal reduction would be performed to correct
incisor protrusion and reduce the overjet, and the dental arches would be aligned.
SOFTWARE DESIGN

Multi-tooth anterior extrusive attachments: Automatically placed on maxillary incisors and

mandibular left lateral incisor due to planned pure extrusion of more than 0.5 mm.

Mandibular incisors: The other mandibular incisors were retroclined to correct incisor
protrusion with relative extrusion, so no extrusive attachments were needed.

Minimal posterior intrusion: A small amount of posterior intrusion was programmed.

Interproximal reduction: Planned to help correct incisor protrusion and align the teeth
without further proclination.
CASE 2
Anterior open bite in Class II malocclusion

A 13-year-old adolescent boy presented with a Class II malocclusion with a 3-mm anterior
open bite and an increased overjet of 5 mm. There was no occlusal contact from first
premolar to first premolar. The patient had a history of thumbsucking and tongue thrust. The
treatment plan involved sequential distalization in to Class I molar and canine relationships
supported by Class II elastics, correction of the anterior open bite by relative extrusion of the
maxillary incisors and pure extrusion of the mandibular incisors, alignment of the dental
arches, reduction in overjet by retraction of the maxillary incisors, and the establishment of
occlusal contact anteriorly and posteriorly.
SOFTWARE DESIGN

Maxillary and mandibular incisor extrusion: Requested on the prescription form to close the
anterior open bite.

Crowding correction: Primarily addressed through dental arch expansion.

Maxillary incisor retroclination: Retroclining and retracting maxillary incisors was requested
to decrease overjet.

Class II to Class I correction: Achieved through sequential distalization of molars and canines.

Multi-tooth anterior extrusive attachments: Placed on mandibular incisors for 0.5 mm or

more of extrusion.

Maxillary incisors attachments: Optimized anterior extrusive attachments were placed on

maxillary right central incisor and left lateral incisor.

Maxillary right lateral incisor attachment: Multiplane attachment for both extrusive and
rotational movements.

Class II elastics: Precision cuts for elastics were incorporated, requiring substitutions on
maxillary canines with vertical rectangular attachments to fit hooks.

Superimpositions: Showed maxillary and mandibular incisor extrusion and half-cusp

distalization for Class I correction.

Buccal superimposition: Demonstrated retroclination and relative extrusion of maxillary

incisors.
CLASS II TREATMENT

Diagnosis and Case Selection

Class II Malocclusions can be skeletal, dental, or a combination of both.

Skeletal Class II involves maxillary prognathism, mandibular retrognathism, or both.
Indicators include:
Increased ANB angle.
Positive Wits analysis.
Vertical skeletal components like brachyfacial (favorable growth) or dolichofacial
(poor prognosis).
Dental compensations include upright/retroclined maxillary incisors and proclined
mandibular incisors.
Treatment starts with distinguishing skeletal vs. dental malocclusion, which determines
the approach.

Treatment Approaches

1. Skeletal Malocclusion (Growing Patients)

Growth Modification:
Appliances: Headgear, functional appliances (Twin Block, MARA, Forsus).
Clear aligners with mandibular advancement feature.
Sequential treatment: Address skeletal issues first, then use aligners for dental
corrections.
2. Skeletal Malocclusion (Nongrowing Patients)
Severe Cases: Orthognathic surgery is required.
Mild Cases: Dental camouflage with extractions (e.g., maxillary first premolars).
3. Dental Class II Malocclusion
Nonextraction treatment:
Aligners with Class II elastics.
Sequential distalization of maxillary molars.
Extraction-based camouflage for significant discrepancies.

Innovative Tools and Features for Class II Correction

1. Precision Cuts: Hooks or button cutouts on aligners for elastic attachment:

Maxillary Hooks: Distal force to retract proclined incisors.
Mandibular Hooks: Mesial force to procline retroclined incisors.
Button Cutouts: For cases requiring independent tooth movement.
2. Power Ridges: Apply lingual root torque for retroclined maxillary incisors.
3. Optimized Root Control Attachments: Facilitate controlled tooth movement during
distalization.
Posterior Interproximal Reduction (IPR)

Prescribed for:
Resolving crowding.
Improving canine or molar Class I relationship.
Reducing distalization requirements.

Class II Elastic Simulation Jump

Class II Elastics:
Used to achieve buccal occlusion correction.
Begin elastic wear early for faster correction compared to fixed appliances.
Precision cuts can be requested in aligners or retainers for continued elastic wear.
Software Simulation:
Monitors progress (spread across aligners or as a final jump).

Key Points for Clinicians:

Tailor treatment plans to skeletal/dental findings.

Growth modification is critical for young patients, while surgical or camouflage options
are for adults.
Clear aligners provide efficient and flexible solutions for Class II correction when paired
with precision cuts, elastics, and IPR.
CASE 1
Class II elastic simulation

A 12-year-old girl presented with minor crowding and a mild Class II discrepancy with
increased overjet. The treatment plan was simply to level and align the arches and correct
the occlusal relationship to Class I with elastic wear.

SOFTWARE DESIGN

Class II Buccal Relationship:

Initial setup showed a mild Class II buccal relationship.

Extrusion for Anterior Open Bite:

Extrusion was programmed into the maxillary right central and lateral incisors to close
the anterior open bite.
Attachments for Tooth Control:

Optimized rotation attachments were placed on the maxillary and mandibular premolars.

Elastics Setup:

Precision-cut hooks were added on the maxillary canines.

Button cutouts were provided on the mandibular first molars to accommodate Class II
elastics.

Class II Simulation Jump:

A Class II simulation jump was incorporated into the software to simulate the effect of
wearing Class II elastics.

CASE 2
Class II elastic simulation
A 28-year-old man presented with a half-cusp Class II malocclusion with increased overjet
and minor crowding in both arches. The maxillary right canine was buccally displaced, and
the maxillary dental midline was deviated 3 mm to the right. It was decided to treat the case
with Class II elastics and some maxillary anterior IPR to (1) correct the Class II buccal
relationship to Class I (molar and canine), (2) correct the maxillary midline deviation, and (3)
align the arches and create space for alignment of the maxillary right canine.

SOFTWARE DESIGN

Class II Buccal Relationship:

Initial setup showed a Class II buccal relationship with:

Buccally erupted maxillary right canine.
Maxillary midline deviation.

IPR in Maxillary Anterior Segment:

Interproximal reduction (IPR) was included in the maxillary anterior segment.

Attachment on Buccally Erupted Canine:

An optimized rotation/extrusive attachment was applied to the maxillary right canine.

Placement of Precision-Cut Hooks:

Due to the incompatibility of certain optimized attachments with precision-cut hooks:

Precision-cut hook was placed on the maxillary right first premolar instead of the
right canine.
Precision-cut hook on the maxillary left quadrant was placed on the left canine.

Mandibular Attachments and Cutouts:

Optimized rotation attachments were applied to the mandibular canines and premolars.
Button cutouts were placed on the mandibular first molars.

Class II Simulation Jump:

A Class II simulation jump was incorporated into the software to simulate the effect of
wearing Class II elastics.

SEQUENTIAL DISTALIZATION
Definition and Purpose:

Sequential distalization involves staged movement of maxillary teeth to

correct Class II malocclusion.
It is effective for addressing half-cusp or full-cusp Class II malocclusions.

Combination with Other Techniques:

Often combined with posterior IPR to reduce the amount of distalization

required.
Class II elastic simulation may be added for interarch anchorage or for
additional correction.

Class II Elastic Support:

Elastics can reinforce anchorage and aid tooth movements programmed

into aligners.
Elastics may be worn full-time or part-time, depending on the patient’s age
and distalization needs.

Anchorage Reinforcement with TADs:

Temporary Anchorage Devices (TADs) may be used for en masse

distalization.
TADs can be engaged with elastics, power threads, or closing coils attached
to precision-cut hooks or power arms.
Palatal TADs may require a transpalatal arch for engagement.

Staging (V-Pattern):

Teeth are distalized in a stepwise manner, creating a "V-pattern":

The second molars move first.
Once the second molar moves halfway, the first molar starts moving, and
so on.
Aligners push teeth distally while anchoring the rest of the dental arch,
minimizing labial movement of incisors.

Class II, Division 2 Differences:

In Division 2 cases, maxillary incisors are addressed from stage 1:

Proclination: Aligning and correcting incisor inclination.
Intrusion: Moving incisors along their long axis.
Retraction: Reducing overjet after leveling the arches.
 Converts Division 2 to Division 1 before completing distalization.

Clear Aligners vs. Fixed Appliances:

Similar principles apply, but clear aligners enable precise staging and
control of distalization without concurrent labial movement of maxillary
incisors

CASE 1
Class II, division 1 malocclusion with sequential distalization

A 16-year-old adolescent boy presented with a Class II malocclusion with increased overjet,
minor crowding in both dental arches, and buccally erupted maxillary second molars. His
mandibular dental midline was deviated 2 mm to the right, and the buccal occlusion was 50%
Class II on both sides. The treatment plan involved decreasing the overjet, aligning the dental
arches, aligning the mandibular dental midline to be coincident with the facial midline, and
correcting the Class II buccal relationship to Class I (molar and canine).

SOFTWARE DESIGN
Staging:

1. V-Pattern Staging:
Classic V-pattern used in the software for sequential distalization.
Mesiobuccal rotation of maxillary first molars was requested to aid Class II to Class I
correction.
Molars distalized into a wider arch form, incorporating maxillary arch expansion.
2. Arch Treatment Sequence:
Mandibular arch treatment completed first.
Passive aligners provided for the mandibular arch while maxillary treatment
continued.
Patient wore Class II elastics during this time to reinforce anchorage.

Attachments:

1. No Attachments for Distalization:

The large surface area of first and second molar crowns provided sufficient
engagement with aligners.
2. Importance of Accurate Records:
Precise capture of the distal surface of maxillary second molars was critical for
predictable distalization.
3. Root Control Attachments:
Placed on premolars and canines for bodily tooth translation.
Mandibular first premolars provided sufficient anchorage for intrusion and leveling of
the mandibular arch.

Precision Cuts

1. Purpose of Precision Cuts:

Precision-cut hooks and button cutouts were used for Class II elastic wear.
2. Elastic Mechanism:
Class II elastics relied on interarch anchorage, with the mandibular arch serving as
anchorage for maxillary arch distalization.
3. Attachment Compatibility:
Optimized attachments and precision-cut hooks could not coexist on maxillary
canines.
Decision made to keep optimized attachments on maxillary canines.
4. Elastic Configuration:
Short Class II elastics were run from precision-cut hooks on maxillary first premolars
to buttons bonded on mandibular first molars.
CASE 4
Class II, division 2 malocclusion with sequential distalization

A 16-year-old adolescent girl presented with a Class II, division 2 malocclusion with a deep
bite of 90%, a 2-mm overjet, retroclined and hypererupted maxillary central incisors, labially
flared maxillary lateral incisors, and a maxillary left canine rotated 45 degrees. The
mandibular incisors were also rotated, and the mandibular dental midline was deviated 2 mm
to the right. The cephalometric analysis indicated a Class II skeletal tendency with incisor
retrusion and increased interincisal angle. The treatment plan involved correcting the deep
bite by intrusion of both the maxillary and mandibular incisors and resolution of the crowding
by proclining the incisors. Power ridges would be placed on the maxillary incisors for lingual
root torque, and the mandibular dental midline would be moved to the left with unilateral IPR
as needed. Sequential distalization would be used to move the molar and canine
relationships into Class I, and the anchorage would be supported with Class II elastic wear.

SOFTWARE DESIGN
Staging

1. Sequential Distalization:
Classic V-pattern staging applied.
Posterior teeth move distally in sequence, starting with second molars.
2. Class II, Division 2 Specifics:
Maxillary incisors start moving from stage 1.
Movements staged as “procline, intrude, retract.”
3. Incisor Movement Sequence:
Proclination: Retroclined incisors are proclined with power ridges and bite ramps.
Intrusion: Bite ramps moved to canines or removed for intrusion along the long axis.
Retraction: Remaining overjet corrected.
4. Mandibular Arch:
Completed first.
Passive aligners provided while maxillary arch treatment continued, enabling Class II
elastic wear for anchorage.

Attachments
 1. No Attachments on Molars:
Molar crowns provided sufficient aligner engagement for distalization.
2. Optimized Attachments:
Maintained on maxillary canines for bodily translation.
3. Vertical Attachments:
Placed on maxillary first premolars to anchor incisor intrusion.
4. Power Ridges:
Incorporated on all maxillary incisors throughout treatment.

Precision Cuts

1. Elastic Integration:
Precision-cut hooks requested for Class II elastics.
2. Elastic Configuration:
Short elastics run from precision-cut hooks on first premolars to mandibular first
molars.
3. Anchorage Mechanism:
Mandibular arch acted as anchorage for maxillary distalization.