Orthodontic clear aligner treatment

Timothy T. Wheeler

Orthodontic treatment with clear aligners is a quickly growing sector of

orthodontic treatment. Both the increase in awareness of esthetics and the
increase in orthodontic treatment demand from adults has fueled the
demand for a more esthetic orthodontic treatment technique. The public
demand for fast and esthetic treatment has been addressed by other dental
sectors with approaches such as “instant orthodontics” in which crowns or
veneers are used to mask malalignment or with products that claim to use
“new techniques” to simply align anterior teeth without addressing other
aspects of the occlusion that may need treatment to maintain a healthy
dentition. Obviously, these types of approaches raise ethical concerns and
the need to educate the public as to the shortfalls of these types of
approaches. Fixed appliances have become smaller and more esthetically
acceptable with the development of ceramic brackets, but they are still more
noticeable than clear aligners. Dozens of companies worldwide now offer
some type of clear aligner orthodontic product. While research has been done
in the area of clear aligners, much of the early research was focused on trying
to discredit the use of aligners as an option for orthodontic treatment except
for minor crowding or spacing cases. Even so, there was some research that
was done to further improve and progress the clear aligner technique. This is
still a rapidly developing area and as a result, much of the literature consists
of case reports. (Semin Orthod 2017; 23:83–89.) & 2017 Published by Elsevier
Inc.

Introduction With these case studies that showed the concept

P
would work, another technique was developing to
rior to 1998, orthodontic clear aligner treat-
treat orthodontic patients. This clear aligner
ment was predominantly for very minor tooth
technique is continually evolving because of
movement, usually at the end of orthodontic
research and development in materials, manu-
treatment or to treat minor alignment relapse. In
facturing techniques, auxiliaries, and computer
1998, Align Technology, Inc. introduced Invisaligns
programming of tooth movement. The aligners
to the orthodontic market. It used computerized 3D
available today are vastly different than those
technology to visualize and move the teeth in a
available in 2000. Many different types of aligners
virtual model. This technology along with advances
are available today throughout the world and
in 3D printing and manufacturing efficiencies
marketed to treat everything from mild to more
allowed aligners to be produced in a large numbers
severe malocclusions.
and in a timely fashion. Initial cases were mild
This article will discuss the current techniques
crowding or spacing1 which progressed to cases that
used for problems that may arise during treat-
needed expansion and/or classification correction.2
ment with aligners, and for treatment of the
more challenging aspects of various maloc-
Department of Orthodontics, University of Florida College of clusions. The available literature for aligner
Dentistry, Gainesville, FL; Diplomate American Board of Orthodon- treatment has grown over the years with several
tics, Jacksonville, FL. clinical trials being done that examine how well
Address correspondence to Timothy T. Wheeler, DMD, PhD, the predicted outcomes compare with the actual
Advanced Orthodontics, 2202 State Avenue, Suite 200, Panama
City, FL 32405. E-mail: [email protected]
outcomes.3–5 However, while this is informative
data, it is only relevant to the aligner system and
& 2017 Published by Elsevier Inc.
1073-8746/12/1801-$30.00/0 materials used and may become dated quickly
http://dx.doi.org/10.1053/j.sodo.2016.10.009 because of the advance made in various

Seminars in Orthodontics, Vol 23, No 1, 2017: pp 83–89 83

84 Wheeler

technologies. As a result, most of the literature overbite while also resolving the crowding.
for current techniques used in clear aligner Unfortunately, the literature contains only
treatment comes from case studies. anecdotal evidence from case studies. National
Dental PBRN is currently conducting a
prospective clinical trial to examine anterior
Treatment with clear aligners openbite treatment success and stability which
Regardless of the aligner system chosen, the will fill a void in the literature.
practitioner should dictate the treatment plan Extrusion of anterior teeth with attachments
which results in how the aligner treatment pro- and intrusion of posterior teeth with the aligner
ceeds and where the teeth are to be moved. This could take an extended amount of time
is true if aligners are fabricated from a series of depending on the amount necessary or may need
models where the teeth have been manually either a greater force(particularly for posterior
manipulated or from digital models in which the intrusion). In these instances, TADs have been
teeth are manipulated by computer or techni- used to facilitate both types of movements.12,13
cians. The following techniques can be used with
most aligner systems, unless specifically noted, to Deepbite
treat the following orthodontic problems. Deepbites are generally treated by anterior
intrusion which can be difficult with aligners. To
Openbite facilitate this movement, Invisaligns uses
attachments on the premolars for anchorage
As with fixed appliances, anterior openbites can
while an active intrusive force is placed on the
be addressed by either intrusion of posterior
incisors (Fig. 2) as well as bite ramps built into the
teeth to allow the mandible to rotate closed, or by
lingual of the aligner of the upper anterior teeth
extrusion of the anterior teeth, or a combination
that act as a bite plane. Incisor intrusion can be
of both. It is up to the practitioner to decide the
difficult with aligners or take a protracted
best approach within the framework of treatment
amount of time and no data exist on the
objectives and stability.
effectiveness of these auxiliaries. In these
Extrusion of anterior teeth can be accom-
instances, intrusion can be facilitated with
plished with attachments.6–8 Attachment shape
TADs. Bowman et al.12 show a very nice
and location have been shown to affect retention
method to intrude upper incisors by creating a
of aligners.9,10 Hennessy11 wrote a recent article
dimpled extrusion of the buccal surface of the
describing the optimized attachments developed
aligner with a Hilliard plier (Dentsply Raintree
for use with Invisaligns including those for
Essix Glenroe, Sarasota, FL) and then cutting a
extrusion of anterior teeth which are pre-
notch. Vertical elastics are then used from the
activated beveled attachments. Even with extru-
notched aligner to TADs placed in the anterior
sion of anterior teeth, an advantage of using
buccal vestibule to provide the intrusive force.
aligners for treatment is the posterior intrusive
affect that the aligners will have on the posterior
Space closure
teeth which also facilitates closure of the anterior
openbite.6 This posterior intrusive affect is Closure of extraction spaces presents the chal-
beneficial in treating cases with crowding and lenge to finish with parallel roots. While this is
minimal overbite. With fixed appliances, true with any appliance, when using fixed
posterior arch expansion may tip the molars or appliances, root-tip bends can be placed in
premolars with equal ease. This tipping results in archwires as necessary to finish the case. How-
extrusion of the lingual cusp. In turn, the ever, aligners present a unique challenge
anterior openbite is made worse. Also with because the goal is to move the teeth with pure
fixed appliances, if crowding is resolved with translation in order to prevent the tipping from
incisor proclination, the outcome of this tipping occurring in the first place because a tipped
is a relative intrusion of the teeth again making tooth is difficult to correct and can take a pro-
the openbite worse. Fig. 1 shows a case with longed time to upright with aligners alone. As a
crowding and minimal overbite. Aligners were result, when using aligners, methods to address
able to control the vertical and maintain the this issue include aligners in combination with
 Orthodontic treatment 85

Figure 1. (A) Initial photos of 12 years 2-month-old girl with Class III tendency, moderate upper and lower
crowding, and a shallow overbite. (B) Final photos after 16 months of treatment with Invisalign. Aligners provide
an intrusive force on the posterior teeth which helps control the vertical dimension. As a result, crowding was
resolved without creating an anterior openbite.

fixed appliances,2 auxiliaries placed on the tooth clinical trials have been done, case studies have
to change the point of force application,14,15 shown that large attachments placed on the teeth
TADs to eliminate unnecessary forces on to be moved may help prevent tipping,6,15 how-
anchorage,14,16 and attachments6,15,17 to ever, experience tells us that this is highly
accomplish this movement. The use of aligners unpredictable. Samoto and Vlaskalic17 recently
and fixed appliances is particularly a good option published treatment of an extraction case treated
when a molar needs to be moved mesial to close using Invisaligns and used knowledge of the
an extraction space or when roots are long which biologic tooth movement cycle to control tooth
increases the probability of tipping as shown in movement and tipping by sequencing which
Fig. 3. TADS have been used as anchorage to teeth were moving at any particular time and
avoid placing forces on teeth that could cause altering the aligner wear time. Preferably,
unnecessary tipping as described by Bowman attachments could be designed to help control
et al.16 Choi et al.14 describes a unique method the tooth movement or the anchorage segments.
using a segmental aligner for the anterior teeth Womack15 and Boyd6 have demonstrated that
and using TADs to retract this segment. While no vertical or horizontal attachments as shown in
86 Wheeler

Crossbites
Difficulty in the correction of crossbites is a factor
of location in the mouth and the depth of the
bite. Minor anterior or posterior crossbites with a
bite depth up to about 10% are usually not dif-
ficult to treat with just the usual aligner treat-
ment. Anterior or posterior crossbites with a bite
depth greater than approximately 10% usually
Figure 2. Attachments placed on premolars provide requires some other considerations to open the
anchorage for the intrusive force place on the upper vertical to allow the tooth in crossbite to clear the
and lower incisors. If no attachments were placed, the opposing teeth such as anterior bite ramps that
anterior intrusive force would cause the posterior of
the aligner to lift off the teeth which would result in
are available on the Invisaligns aligners or
little, if any, intrusive force applied. placing cold-cure acrylic on the occlusal surface
of the aligners while the crossbite is being
jumped. In order to avoid occlusal trauma to the
Fig. 3A on the molars, premolars, or canines can
teeth as the crossbite is correcting, the aligners
help, but there is no reported data that shows
may need to be worn full-time including while
efficacy, and as shown in Fig. 3B and C this does not
eating until the crossbite is jumped. Crossbite
always work and can result in molar tipping which is
correction of posterior teeth as shown in Fig. 5A
also frequently seen in treatment with fixed
may be facilitated by placing attachments on the
appliances as well. Correction of this tipping often
lingual (Fig. 5B) and/or using crossbite elastics
requires a period of fixed appliances as shown in
(Fig. 5C) when the movement is programed in
Fig. 3D and E. Recently, Invisaligns developed
the aligners. The result of this type of setup is
attachments to control posterior anchorage in cases
shown after 3 months in Fig. 5D and E.
requiring extraction and retraction of anterior
teeth. These strategies work by placing a force
that creates a moment in the opposite direction to Extrusion/settling
counter the tipping moment (Fig. 4A). Since these Often a ClinCheck for Invisalign will require the
are new, little has been reported, but as seen in teeth to extrude into the final desired occlusion.
Fig. 4B and C after 6 months of treatment, the upper While attachments are automatically placed to
posterior anchorage segment appears to be facilitate this movement when a threshold of
maintaining its original position. greater than 0.4 mm is reached, movements less

Figure 3. (A) Rectangular attachment was placed on the lower 1st molar as a preventative to crown tipping during
mesial movement of the molar needed for correction of the Class II. However, molar tipping may occur as seen in
(B) and (C). This can be corrected easily with a period of fixed appliances as seen in (D) and (E).
 Orthodontic treatment 87

Figure 4. (A) Attachments on the upper molars and 2nd premolar are pre-activated when placed which creates a
clockwise moment to oppose the counter-clockwise moment created when retracting the anterior teeth. (B) The
clincheck illustrating where teeth should be after 6 months of treatment which is confirmed in (C).

than this are expected to occur unaided. Fre- presented several cases where he used
quently, this does not occur and gingival beveled attachments on molars and premolars to
attachments can manually be placed on the sequentially distalize the maxillary dentition to
desired teeth in the ClinCheck. As another a Class I without the use of Class II elastics. In one
option, vertical elastics from buttons can also be of the cases, 2nd molars were extracted to
used to facilitate this movement independent of facilitate the distalization. As in space closure,
the magnitude of the movement (Fig. 6). pure translation during distalization can be
difficult with aligners or fixed appliances.
Often the posterior teeth are tipped back and
Class II correction care must be taken to then distalize the root and
The correction of a Class II malocclusion with prevent the crown from relapsing and tipping
aligners can be treated much like as it is done forward. This movement can be difficult with
with fixed appliances. While no clinical trials aligners due to force necessary to create the
have been done to determine which methods moment that will distalize the root. In addition,
might be the better choice with aligners, treat- anchorage for the distalization comes from the
ment options range from distalization of the anterior teeth and flaring or anterior movement
upper dentition to protraction of the lower may occur. This is usually controlled by using the
dentition or a combination of both. In younger lower arch for anchorage with Class II elastics
patients, mandibular growth can also help in the which can then also assist in distalizing the upper
correction of the Class II malocclusion. Fischer18 dentition19 as well as protracting the lower

Figure 5. (A) Patient with crossbite of all premolars and molars was treated with lingual attachments on the upper
premolars (B) and crossbite elastics from buttons placed on the lingual of the upper molars and buccal of the lower
molars (C). Crossbite correction can be seen in a scan after 3 months of treatment (D) and the clinical treatment
photo (E).
88 Wheeler

attachments will continue to improve which will

allow aligners to fit better and for longer periods
of time and result in better outcomes. Research
into tooth movement and particularly tooth
movement mechanics with aligners and the
variation in these movements will allow further
development of computer algorithms that are
used in sequencing aligner tooth movement.
Figure 6. Clincheck showing precision cut-outs where
buttons are placed for vertical elastics to help settle the Even so, with the amount of variation that is seen
posterior occlusion. in orthodontic treatment, it will always take a
knowledgeable practitioner to treatment plan
dentition. As with space closure, TADs placed and monitor treatment with aligners.
either in the buccal or the palate can be used as
anchorage to distalize the upper dentition to Class I
or to retract the anterior teeth after extraction of References
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