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Invisalign for a Special Needs Child Wm. Randol Womack, DDS, Board Certified Orthodontist Editorial Director, Orthotown Magazine

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On July 10, 2008, I examined a six-year-old autistic patient that was referred by his pediatric dentist for evaluation of a large diastema between the upper central incisors. The unsightly space between the centrals was exaggerated by a previous medical intervention during a tonsillectomy. The ENT physician informed the parents that during the tonsillectomy he assisted the dental issue of the diastema by doing a "frenectomy." Figures 1a and 1b show the condition that existed at the initial examination. Notice that the interdental papilla, which is normally there (Fig. 2), was now absent after the "frenectomy."

I discussed the upper central diastema issue with the parents and they commented that he was very aware of the looks of his teeth and he didn't like them. We considered fixed appliances but mom was concerned that he might not adjust to the "hardware" and the irritation of fixed appliance treatment. I suggested that we consider Invisalign to correct the diastema. This option was attractive to the parents but his acceptance of Invisalign treatment and the ability to comply with the treatment as required was still in question.

We decided to make an Essix appliance as a "test aligner" to evaluate how he would accommodate wearing a removable plastic appliance (Fig. 3).

We inserted the "test aligner" on July 17, 2008 and reappointed him in 30 days. Two weeks after delivering the Essix appliance, the patient was back in the office and the appliance was severely distorted. Mom said he tended to chew on it a lot. We made a second "test aligner" and saw him again in two weeks. This time the Essix appliance was fitting well enough and he had adjusted to it well enough to go forward with Invisalign PVS impressions. We had his pediatric dentist use light nitrous sedation for the impression appointment (Figs. 4a-4c) and we were successful in obtaining good quality impressions.

The ClinCheck for this case showed good correction of the upper centrals in 26 stages. Increments were 0.15mm/stage. (Figs. 5a-5b).



We delivered the first three Invisalign aligners on October 1, 2008, and instructed mom that he was to change the aligners every 10 days. At the next appointment mom stated that the aligners got very loose toward the end of the 10-day interval and it was decided that changing every seven days would be advisable.

The treatment ended on April 7, 2009 (Fig. 6).

There was still a small open contact between the centrals, so new PVS impressions were made in our clinic (no sedation required now) and refinement aligners were ordered and delivered on May 7, 2009 (five stages). Refinement was complete by June 11, 2009 (Fig. 7).

In November, the upper lateral incisors were beginning to erupt. An additional refinement was done (Fig. 8). This refinement used the Invisalign Teen ClinCheck, which provided eruption pockets in the refinement aligners to guide the laterals into position (eight aligners). On December 17, 2009, all the aligners were delivered at one time to mom with instructions to change them every seven days. The second refinement was finished in eight weeks. The patient was seen on April 1, 2010, with all four upper incisors in good alignment (Fig. 9).

Discussion
This treatment regimen challenged several accepted principles. First, the application of Invisalign treatment to a very young patient (under age 8). As far as I know, this is way outside the box of conventional thinking for Invisalign treatment. However, when reviewed in light of the patient's special needs, it is a very logical application of treatment. Second, the success of this treatment speaks volumes for the versatility of Invisalign as an option in the diagnosis and treatment of special-needs patients, specifically patients with autism. Third, the staging of the ClinCheck enabled the aligners to be changed weekly instead of every 14 days. This proved to be a benefit in forming a "habit pattern" that was embraced by this autistic patient. His mother told me that, early on in the treatment he looked forward to the day (each week) when he got his "new brace" for his teeth. Fourth, he adapted quickly to our office environment and became very manageable (without sedation) for taking impressions and adding or removing attachments.

The Invisalign Teen treatment program was an advantage in continuing a second phase of treatment by providing "pockets" to guide the developing upper lateral incisors into place as they were erupting.

Conclusions
This special-needs patient was successfully treated with the Invisalign System even though he was not in the conventional age group for typical Invisalign candidates. His mother testifies that the success of this treatment produced a significant positive effect on his personality development and self-assurance, saying, "He smiles a lot!"

This is the first of several other special-needs patients that are in treatment with Invisalign, one of which is seven years old and another age 15. I hope that this will open awareness of an application for orthodontic treatment for patients younger than the previously conventional 12-year-old base age and for special-needs patients at any age.

To view the mother's interview about his treatment, go to: www.youtube.com/user/DrRandolWomack
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