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APOS Trends in Orthodontics
Special Feature
The hybrid approach: A solution to overcome
unpredictable movements in clear aligner therapy
Luca Lombardo1 , Paolo Albertini1 , vsGiuseppe Siciliani1
Department of Orthodontics, University of Ferrara, Via Borsari, Ferrara, Emilia Romagna, Italy.
1
ABSTRACT
The clear aligner system has been radically improved in many aspects: New materials, protocols, attachments,
and auxiliaries were developed to improve biomechanics. Many movements remain unpredictable, outlining the
limits of clear aligners treatment, but a hybrid approach, which combines clear aligners with fixed appliance, is
an efficient treatment alternative. This approach significantly reduces overall treatment time and unpredictable
movements. The aim of this article is to show the application of the hybrid approach for different types of
*Corresponding author:
movements.
Luca Lombardo,
Department of Orthodontics, Keywords: Clear aligners, Fixed appliances, Hybrid approach
University of Ferrara, Via
Borsari, Ferrara, Emilia
Romagna, Italy.
INTRODUCTION
[email protected]
Clear aligners have become increasingly popular in recent years due to patients’ esthetic and
Received : 12 April 2020 comfort needs.
Accepted : 20 May 2020 Young patients between the ages of 8 and 16 have a strong self-perception regarding smile
Published : 30 June 2020 esthetics and, therefore, not only adults require orthodontic treatment with the use of esthetic
appliances.[1,2]
DOI
10.25259/APOS_48_2020 In the last years, the clear aligner system has been radically improved in many aspects: New
materials, protocols, attachments, and auxiliaries were developed to improve biomechanics.
Quick Response Code:
A careful patient selection is necessary since the clear aligners therapy is a valid alternative only
for non-extraction cases, which fit in determined diagnostic parameters.[3]
For more severe cases, fixed appliances are needed since clear aligners therapy is less efficient.[4-6]
Recently, a meta-analysis has concluded that orthodontic treatment with aligners is associated
with worse treatment outcome compared to fixed appliances in adult patients.[7]
The outcomes are closely related to the predictability of the planned dental movements.
The software to create aligners setup simulates any type of dental movement, even those
achievable only with orthognathic surgery; therefore, planning the case requires attention.
The international scientific literature is very clear and agrees in describing which movements are
achievable and which are unpredictable with clear aligners.[4-7]
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APOS Trends in Orthodontics • Volume 10 • Issue 2 • April-June 2020 | 72
Lombardo, et al.: The hybrid approach in clear aligner therapy
The aligners accuracy is sufficient to resolve anterior In fact, when a transverse diameter expansion with dental
crowding and molar distalization (2.5 mm), but inadequate tipping is necessary, due to an excessively negative inclination
for bodily expansion of the maxillary posterior teeth, canine of the posterior teeth, only clear aligners are ideal; however,
and premolar rotational movements, extrusion of maxillary as in most cases, when a bodily expansion is needed, only
incisors, and in overbite control.[5] clear aligners are no longer sufficient.
Many movements remain unpredictable, outlining the For these reasons, the hybrid approach consists of a phase,
limits of clear aligners treatment, which can be sometimes before F22 clear aligners treatment, with rapid palatal
overcome only using fixed appliance, as extraction cases or expander with or without miniscrews, depending on the
severe malocclusions. patient age.
In alternative, the innovative concept of hybrid approach In adult patients, the expansion supported by miniscrews
implies the use of partial fixed appliances combined with improves the bodily movements [Figure 2].
clear aligners.
SAGITTAL CORRECTION – CLASS II
The aim of this article is to show the application of the hybrid
approach for different types of movements, which would be In literature, a bodily distalization of 2.2 mm is possible to
unpredictable with the application of clear aligners only. achieve, planning 0.25 mm of movement per step and asking
the patients to wear aligners 14 days each.[9]
ROTATIONS CORRECTION This amount of distalization is sufficient to correct at most a
half cusp Class II relationship.
The ability to rotate teeth strongly depends on the tooth
anatomy and how the pressure points grip the tooth. However, to minimize loss of anchorage, hybrid approach
consists of intermaxillary elastics applied on sectional
In literature, the accuracy of clear aligners is described as
archwires or Carriere Motion, and in cases, where a greater
inadequate to derotate canines and premolars.[5]
sagittal correction is required, it consists of TADs appliances,
Rounded teeth are the most difficult teeth to control with such as pendulum on miniscrews [Figures 3 and 4].
aligners (1/3 of that predicted), unlike the upper incisors, Upper wisdom teeth might be extracted to take advantage of
which are easier to rotate due to the greater mesiodistal width the regional acceleratory phenomenon.
and to the flatter shape.[4,6]
Once the desired sagittal correction is obtained, the F22 clear
The hybrid approach, especially on the most difficult teeth to aligners are used for the case finishing [Figures 3 and 4].
derotate, consists of a fixed partial lingual appliance to obtain
greater movement predictability, a reduction in the number
SAGITTAL CORRECTION – CLASS III
of attachments in esthetic areas and a limited number of clear
aligners. In literature, there is no evidence about lower arch
The first step of this procedure is to place lingual tubes on distalization movement and upper arch mesialization
movement.
the rotated teeth and on the adjacent teeth; then, an accurate
impression is necessary to simulate the presence of a lingual The sagittal correction of mild Class III can be obtained with
archwire in the setup and to keep the physical space under the intermaxillary elastic combined with clear aligners, but
the clear aligners (F22; Sweden and Martina, Due Carrare, sometimes this solution is not resolutive.
PD, Italy) [Figure 1]. For these reasons, the hybrid approach consists of a phase
F22 aligners completely envelope the partial fixed lingual before clear aligners with hybrid or traditional rapid palatal
appliances and follow the CuNiTi archwires expression expander combined with facemask [Figure 5].
[Figure 1]. Once the desired sagittal correction is obtained, the clear
aligners are used for the case finishing [Figure 5].
TRANSVERSAL CORRECTION
VERTICAL CORRECTION
In literature, the bodily transverse expansion with clear
aligners is not predictable and the setup tends to overestimate In literature, pure intrusion and extrusion movements
bodily expansion movements.[5,8] are unpredictable with clear aligners and proclination or
The transverse dimensions increase is often due to tipping retroclination is clinically planned to mask vertical problems.[10,11]
movement of the teeth, even if bodily expansion movements However, this type of correction is allowed when the amount
were planned.[8] of vertical correction is very limited.
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Lombardo, et al.: The hybrid approach in clear aligner therapy
a b c
d e f
Figure 1: Rotations correction: (a) Lingual tubes placed on the rotated teeth and on the adjacent teeth followed by impressions; (b and c)
beginning of the hybrid treatment with clear aligners combined with a 0.013 CuNiTi archwire insertion in lingual tubes; (d) 2 months later,
the clear aligners continue to follow the CuNiTi archwire expression; (e and f) 4 months from the beginning, the rotation is corrected;
(g) final result.
a b c d
e f g h
i j k l
Figure 2: Transversal correction: (a and b) Initial photographs show the transverse diameter reduction in an adult patient; (c and d) beginning
of the hybrid treatment with RPE supported by miniscrews; (e and f) end of expansion phase and impressions performed for a clear aligners
phase; (g and h) clear aligners phase; (i and j) clear aligners refinement phase; (k and l) end of hybrid treatment and RPE remotion.
APOS Trends in Orthodontics • Volume 10 • Issue 2 • April-June 2020 | 74
Lombardo, et al.: The hybrid approach in clear aligner therapy
The upper incisors intrusion is described as the most Furthermore, extrusion movements are unpredictable and
unpredictable movement with clear aligners, especially in only 29.6% of the movements planned in the setup are
severe deep bite malocclusions, and a bite opening of 1.5 mm achieved at the end of clear aligners treatment. However,
could be obtained due to lower incisors proclination rather there is an increasing evidence that aligners are effective in
than true bodily intrusion.[11,12] open bite cases, obtaining a significant amount of incisor
a b c
d e
Figure 3: Moderate sagittal correction: (a) Initial photographs show a molar Class II relationship on the right side in an adult patient;
(b) beginning of the hybrid treatment with Carriere Motion and clear aligners; (c and d) once the desired sagittal correction is obtained, the
F22 clear aligners are used for the case finishing; (e) final result.
a b c d e
f g h i j
k l m n o
p q r
Figure 4: Severe sagittal and transversal correction: (a-c) Initial photographs show a molar Class II relationship on the left side and transverse
diameter reduction in an adult patient; (d-f) beginning of the hybrid treatment with RPE/pendulum supported by miniscrew and F22 clear
aligners; (g-i) once the desired sagittal and transversal correction are obtained, (j-l) the F22 clear aligners are used for the easier case; (m-o)
case refinement; (p-r) final result.
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Lombardo, et al.: The hybrid approach in clear aligner therapy
a b c d
e f g h
i j k l
m n o p
q r s t
u
Figure 5: Sagittal correction: (a-c) Initial photographs show a Class III malocclusion in a young patient; (d-f) beginning of the early treatment
with traditional RPE combined with facemask; (g-i) early treatment is finished; since the sagittal correction was not sufficient, (j-l) an hybrid
treatment with RPE supported by miniscrews combined with facemask and F22 clear aligners was performed; (m-o) once the desired sagittal
correction is obtained, (p-r) the F22 clear aligners are used for the case refinement; (s-u) final result.
palatal tipping and extrusion.[13] The difficulty in achieving to simulate the presence of a lingual archwire in the setup
pure extrusion is likely due to the poor grip of the aligners and to keep the physical space under the F22 clear aligners
on the teeth. [Figure 6].
If the vertical correction is limited to few teeth, the hybrid The aligners completely envelope the partial fixed lingual
approach consists of fixed partial lingual appliances with appliances and follow the CuNiTi archwires expression
different heights of the tubes, to facilitate the movements [Figure 6].
planned [Figure 6]. The position of lingual tubes depends However, the vertical malocclusions could be related to
on the difference in height between the interested teeth and different problems and the diagnosis remains the essential
the adjacent teeth; then, an accurate impression is necessary object to choose the correct treatment plan.
APOS Trends in Orthodontics • Volume 10 • Issue 2 • April-June 2020 | 76
Lombardo, et al.: The hybrid approach in clear aligner therapy
a b c d
e f g h
Figure 6: Vertical correction: (a and b) Initial photographs show an anterior open bite in an adult patient; (c and d) beginning of the hybrid
treatment with F22 clear aligners combined with a 0.013 CuNiTi archwire insertion in lingual tubes, which were placed at different height to
facilitate the planned movements; (e and f) case refinement after CuNiTi archwire complete expression; (g and h) final result.
CONCLUSIONS Orthod 2015;85:881-9.
5. Papadimitriou A, Mousoulea S, Gkantidis N, Kloukos D.
Hybrid approach using clear aligners combined with partial Clinical effectiveness of invisalign orthodontic treatment: A
fixed appliances is an efficient treatment alternative to systematic review. Prog Orthod 2018;19:37.
avoid unpredictable movements. Moreover, this approach 6. Kravitz ND, Kuznets B, BeGole E, Obrez A, Agran B. How well
significantly reduces overall treatment time without a marked does invisalign work? A prospective clinical study evaluating
increase in cost. the efficacy of tooth movement with invisalign. Am J Orthod
Dentofacial Orthop 2009;135:27-35.
7. Papageorgiou SN, Koletsi D, Iliadi A, Peltomaki T, Eliades T.
Declaration of patient consent Treatment outcome with orthodontic aligners and fixed
Patient’s consent not required as patients identity is not appliances: A systematic review with meta-analyses [published
online ahead of print. Eur J Orthod 2019;2019:cjz094.
disclosed or compromised.
8. Houle JP, Piedade L, Todescan R Jr., Pinheiro FH. The
predictability of transverse changes with invisalign. Angle
Financial support and sponsorship Orthod 2017;87:19-24.
9. Ravera S, Castroflorio T, Garino F, Daher S, Cugliari G,
Nil. Deregibus A. Maxillary molar distalization with aligners in
adult patients: A multicenter retrospective study. Prog Orthod
Conflicts of interest 2016;17:12.
10. Galan-Lopez L, Barcia-Gonzalez J, Plasencia E. A systematic
There are no conflicts of interest. review of the accuracy and efficiency of dental movements
with invisalign. Korean J Orthod 2019;49:140-9.
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