Vertical Control in Clear Aligner Therapy by Dr. Mike DePascale

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Vertical Control in Clear Aligner Therapy 

Open bites and deep bites

by Dr. Mike DePascale

Let’s talk about clear aligner control and treatment planning design. I’m excited about this piece as it comes in an unexpectedly timely fashion, shortly after a recent poll was conducted in one of the most prominent orthodontic Facebook groups regarding the predictability of the results for patients treated with clear aligners versus brackets and wires. The outcome was extremely unbalanced in favor of fixed appliances. This got me thinking: Why is that?

If we had an endless number of hours to banter back and forth, we could probably take up every bit of that time “arguing” over which is “better.” But I’m not here to do that. Though I teach primarily about clear aligners, that is specifically because my passion lies in this area of orthodontics, not because I dislike braces. Trying to label which of them is “better” is really an exercise in futility, as that is a delicate, nuanced balance between a myriad of factors including choice of bracket, type of case being treated, periodontal status of the patient, the operator (this is a huge factor), patient commitment, patient goals, etc. I do believe that there are specific malocclusions and patient populations that lend themselves to better treatment with removable appliances, and the converse is true as well.
Pretreatment facial and intraoral records showing deep bite, narrowness, and crowding
Fig. 1

Vertical Control in Clear Aligner Therapy
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Vertical Control in Clear Aligner Therapy
Initial pan

However, there are two points I wish to drive home today, and I know they will ruffle some feathers, but here we are. The first is this: The idea that clear aligners cannot treat what braces can or to the same level is one that simply should be put to rest. The second is: If YOU, the person reading this, have a desire to elevate your aligner treatment to the same level of results and patient experience as you deliver with braces, or better, there is enough education out there to get you there. You simply have to commit the time and effort to do so.

This is where I believe that poll was so heavily skewed in one direction. The vast majority of orthodontists, as it currently stands, simply do not have nearly as much education or experience in removable appliances as they do with fixed, and as such, feel that one is inferior. If you make it through this article, I’ll at least get you started in changing that.

Treating deep bites with aligners is a fun topic because most still feel they cannot be treated well, and I believe this is simply a result of misdiagnosis and/or inadequate case design, not the appliance itself. The foundation of my staging protocols is rooted in several important design principles. Correcting a deep bite is simply an extension of that.

To start almost every case, I sequence the following things simultaneously: Constrict all 7s (or terminal tooth) with buccal root torque on upper and lingual root torque on lower while expanding the 456s and adding mesial out and BRT to the 6s; procline anterior teeth with hinge rotations to alleviate crowding; slightly intrude anterior teeth during proclination; once aligned, plan IPR, and then retract, intrude, and add LRT at the same time. What I love about this foundation is that deep bites apply all of these principles and vary only slightly as needed. The finish position will be adjusted based on case complexity. In general, the more severe the overbite, the more you will “overtreat” the opening, though it is not as much as one might think. As a general guideline, you rarely, if ever, need to overtreat the overbite from a normal 2 mm in children.

In adults, the more brachycephalic and/or worn their dentition is, the more you have to compensate for this (think big burly lumberjack man in his late 50s who has been wearing his teeth down since 1994; those are tough, and you must account for that).

Here are the most common errors that I see with case design:

1. The procline phase does not get completed.
  • The retroclination of the upper and lower incisors has to be fully removed (sometimes even overcompensated) before initiating the retraction phase for this to go smoothly.
2. There is not enough lingual or palatal root torque of the upper incisors during the retraction phase.
  • This is a big one. Often what will happen is that the procline phase was appropriate and the desired torque was achieved, but then it was lost during the retraction. What will happen in cases like this is in the middle of treatment, things will be going predictably, but at the end of the set of aligners, the patient is left once again with a deep bite (or posterior open bite). Check your torque!
3. Compensation of anterior torque is not added in conjunction with expansion.
  • The more transverse width you are creating, the greater tendency you have for the incisors to be retroclined. You must account for this in your setup. One degree of lingual or palatal root torque per aligner of retraction is a good place to start.

4. Intrusion is not occurring through the entire process.
  • You should be programming relative intrusion through the procline phase and continuing through the retrocline phase, but make sure that the intrusion is not pure intrusion.
  • If pure intrusion is planned, what will sometimes happen, in particular on the lower arch, is the roots will intrude to the facial aspect of the cortical plate and the movement will stop. As the aligner continues to push, the side effect is retroclination (see #2 above).
The finish position of these teeth does vary from my normal setup. My typical occlusal contacts will be heavy in the posterior (red on the software) and light (green) to none in the anterior. When treating a deep bite, I will increase both of those: heavier contacts in the posterior and no contact in the anterior.

Shown is an example of a patient that presented with near 100% deep bite, narrowness, crowding, and a UR7 in buccal crossbite (Fig. 1). Remember, all you need to do is diagnose and follow the script. One of the views that is most important to check on the software is the buccal side with curve of Spee correction (Figs. 2 and 3). You must make sure that the COS is level and the incisors are fully proclined.
Digital setup showing curve of Spee correction, buccal view
Fig. 2
Digital setup showing curve of Spee correction, buccal view, opposite side
Fig. 3

I have also shown the refinement stage (Fig. 4) to give you an example of one of the few ways that you can create a posterior open bite unintentionally. Here, it was loss of posterior torque control during expansion. This is not a big deal if you diagnose correctly. Because I did, the fix is simple. Simply add buccal root torque to the posterior teeth with no expansion, achieve relative extrusion, and you’ll be home soon (Fig. 5). You can appreciate the change in vertical overbite in her before and after (Fig. 6), which we achieved in just 11 months and two sets of aligners (Fig. 7).
Refinement stage intraoral and digital records
Fig. 4
Facial and intraoral photos after correction of posterior open bite
Fig. 5
Before and after intraoral photos showing change in vertical overbite
Fig. 6
Before and after smiling photos of patient treated for deep bite
Fig. 7
Vertical Control in Clear Aligner Therapy
Final ceph
Vertical Control in Clear Aligner Therapy
Final pan

Treating anterior open bites effectively with aligners is a more nuanced topic, as many more orthodontists are confident in this treatment modality for that specific malocclusion. Please remember that it is not simply because there is plastic between the teeth, although that helps. I believe this is primarily a diagnosis and treatment planning win. Most orthodontists, when treating anterior open bites with braces nonsurgically (and without TADs), will use anterior elastics only to close the bite. Severe extrusion of anterior teeth with elastics is an unstable movement. Many of these cases should be treated primarily with posterior intrusion or some combination of posterior intrusion with mild anterior elastics. Importantly, I’ve never closed an anterior open bite with aligners using elastics. That is not to say that you can’t or necessarily shouldn’t, but understand it is not required, and relying on that is probably part of the reason treatment is unsuccessful. The best way to treat these cases is with posterior intrusion using posterior bite turbos. This could easily be done with braces as well, but for some reason, it is still not the norm.

The foundation of my mechanics is the same as listed above. My anterior open bite staging, though, changes with one main difference and a few important focus points.

1. Achieve transverse arch width before intrusion if using TADs.

2. Intrude the posterior teeth to the level of the incisors and program a vertical bite jump to simulate bite closure.
  • This is primarily how the open bite is closed.
  • Remember that you will get relative extrusion of the upper incisors (and frequently will want some, as most of these patients have a reverse smile arc and excess posterior gingival display).
  • If you do truly need more upper incisor extrusion for smile arc, change the design so that you achieve the vertical position of the incisors to your liking and then intrude the posterior teeth to that level.
  • As with other cases, the more severe the intrusion, the more likely you are to overtreat it. Keep in mind this overtreatment amount is generally minimal at 0.5–1.5 mm.
  • If you are using TADs for intrusion, do not overtreat at all.
3. Make sure to control posterior torque during intrusion: Add extra BRT by 5–10 degrees as needed. Most will plan several degrees of BRT per millimeter of expansion, but you may need to add more intrusion if severe.

4. Finish position will have light (green or slightly no) posterior contacts and green anterior contacts.

5. The more severe the AOB, the more likely you’ll need to increase intrusion of 7s more than 6s.

6. Design with both Class II and Class III elastics. Depending on the arc of closure of the bite, you may need either one.
Patient with severe narrowness, crowding, and anterior open bite
Fig. 8
Pretreatment intraoral frontal photo showing anterior open bite
Fig. 9
Pretreatment intraoral lateral photo, right side
Fig. 10
Pretreatment intraoral lateral photo, left side
Fig. 11
Digital treatment plan showing intrusion setup
Fig. 12
Digital treatment plan, planned position before bite jump
Fig. 13

Vertical Control in Clear Aligner Therapy
Initial ceph
Vertical Control in Clear Aligner Therapy
Initial pan

The patient shown here (Fig. 8) has severe narrowness and crowding with an anterior open bite (Figs. 9–12). Using the above protocols, this can be treated very effectively. If I treated this case tomorrow, I would intrude the posterior 0.5–0.7 mm more to account for the planned movement on the anterior teeth, but you can see to the level it was planned (Fig. 13, before bite jump; Fig. 14, overlay of movement before bite jump). We eliminated the crowding and anterior open bite and achieved a great result with upright posterior segments, a beautiful smile arc, and great arch width. Most importantly, we have a very happy patient! (Figs. 15–18) Please note that in Figure 16, the photos are size corrected—the red and green lines are the same size.
Overlay of movement before bite jump
Fig. 14
Post-treatment intraoral frontal photo showing closed bite
Fig. 15
Occlusal photos with size-corrected arch width measurement lines
Fig. 16
Pre- and post-treatment intraoral comparison photos
Fig. 17
Before and after smiling photos of patient
Fig. 18
Vertical Control in Clear Aligner Therapy
Final ceph
Vertical Control in Clear Aligner Therapy
Final pan


The biggest thing I want you to bring back to your practice from all of the information presented is that aligners can very effectively achieve vertical control in tooth movement. You, as the orthodontist, must make sure that teeth are moving appropriately to achieve this goal, and the rest will follow. So if you feel stuck with your clear aligner treatment, but you want to be better, just keep moving. The information is there. The techniques are there. You just need more reps. Stay tuned for more mechanics coming later this year. As always … do more, be more, smile more.
Author Bio
Dr. Mike DePascale Dr. Mike DePascale, New Jersey native, received his orthodontic master’s degree at the University of Maryland in Baltimore. In 2017, he joined the team at Kozlowski Orthodontics, a practice that matched his dedication to high-quality treatment, innovation, efficiency, and education. When DePascale is not in the office, you can find him in his garage gym or coaching CrossFit at a local gym, where he puts to use his passion for personal growth, leadership, and commitment to others. He believes in pushing boundaries, doing what you love and sharing that with the world.
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