Clear aligner treatment has significantly improved over the last decade. Initially used for mild alignment treatment, aligners have progressed into treating more complex malocclusions.
A 30-year-old male with a Class I malocclusion presented with a concern of generalized spacing in both the maxillary and mandibular dental arch. The patient had a slight tongue protrusion that resulted in an anterior open bite. The open bite was more pronounced on the left side. The patient had orthodontic treatment as a child and stated that the spaces were closed at the end of the initial treatment.
Periodontally, the patient presented in good health, both dental and gingival. There were no TMD symptoms, and jaw movements were normal.
The patient mentioned that he regularly interacted with people as a part of his job, and that he dreaded how his teeth would appear with braces. Because of his public job, he requested a clear aligner treatment. Diagnostic records were taken with PVS impressions as well as photos to fabricate ClearCorrect aligners (Figs. 1-10).
The case and associated materials were submitted to ClearCorrect via its online doctor’s portal, ClearComm. Photos were uploaded here and PVS impressions were mailed separately. Once ClearCorrect received all records, the proposed treatment plan (called a treatment setup) was sent to our offices within one week.
At this same time, our offices received aligner cases and a set of starter aligners. The starter aligners are designed to slowly ease the patient into treatment.
Upon seating the starter aligners, we discovered that the lower left flange would not seat. This was an indication that the original impressions submitted were not accurate. A new set of impressions was taken and within a week a new treatment setup and starter aligners were received.
We seated the starter aligners and they fit like a glove. We then accepted the treatment setup, and production of the aligners began. The treatment setup indicated that 20 aligners would be needed to correct the patient’s malocclusion, along with an estimated 0.6mm of interproximal reduction.
We received the first phase of treatment. ClearCorrect ships their aligners in what is called a phase, which includes four sets of aligners. You do not receive all the aligners at once. This is beneficial in case a revision is needed during treatment, and this way there’s no cost to do so.
We seated the first set of aligners, and gave the patient the second set to take home and change on his own after three weeks. We saw the patient again after six weeks. At the following appointment, and before seating the third set of aligners, engagers were placed from maxillary canine to canine, and mandibular teeth #19, 20, 24, 25, 29 and 30, for a total of 12 engagers. An engager template was provided for easy placement.
Heavy-filled composite was used for the engagers, similar to what is used for a Class IV composite. I have found that a heavy-filled composite resists attrition of the composite from the continual insertion and removal of the aligner. I used Southern Dental
Industries glacier composite, because it’s very resistant to wear and has low shrinkage properties. At the same the engagers were placed, a total of 0.3mm interproximal reduction was needed between the right and left first molar and second premolar. The patient was given his fourth set of aligners to take home and change on his own after three weeks. We would see the patient again in six weeks.
Treatment progressed smoothly during the second and third phases of treatment. During the fourth phase of treatment however, the aligners were not seating as well as they previously had been. New impressions and photos were taken to make minor revisions within the alignment and to further complete the patient’s treatment (Figs. 11-18).
Specifically, the left canines (where the open bite was more pronounced) needed more closure. Even with this revision, the treatment was still completed within 20 aligners. Even with the revision there was no adjustment in fees or cost.
Upon completion of the fifth phase, treatment was complete (Figs. 19-28). Bonded maxillary and mandibular retainers were placed with clear thermoformed trays over them as part of his retention protocol. Aesthetic bonding completed tooth #9 where there was excessive wear of his incisor (Fig. 29). Both the patient and I were very pleased with the results achieved.
Management of an anterior open bite with clear aligners presents many advantages. A significant importance of correction includes managing posterior-extrusion during treatment, decreasing torque of the incisors, and removing any barriers that would interfere with the dentition from closing.
Aligners, because of their thickness, can create an intrusive force on the molars that helps with correction of the open bite. The aligners can also create a barrier to any tongue thrusting and help keep the tongue back so as not to interfere with closure. Specifically in this case, the closure of the patient’s anterior open bite was produced by “detorquing” the incisors to close his spaces, and intrusive forces on the molars to reduce posterior contacts.
Dr. Edward Davis completed his Doctorate of Dental Medicine at the Medical University of South Carolina. Following dental school he participated in a year of advanced dental training in the graduate residence program at Columbia’s Palmetto Richland Memorial Hospital. Dr. Davis underwent training in the specialty of orthodontics at St. Louis University’s Center for Advanced Dental Education, where he was awarded his certificate of orthodontics and an MS in oral biology. Dr. Davis is one of the few board-certified orthodontists practicing in the Columbia metropolitan area and Orangeburg. Dr. Davis has been practicing orthodontics since January 2001. He participates in many professional organizations and strives to stay up to date with all the latest advances in orthodontics and dentistry.