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An Adult Non-Extraction Expansion-Aligner Case by Ken Fischer, DDS

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Introduction
After successfully getting her three children completely through orthodontic treatment, this 45-year-old woman (Fig. 1) wanted to have her crooked teeth straightened, but not without conditions. She did not want any of her teeth removed and she insisted that she be treated with Invisalign. Her treatment began early in 2002, only a couple of years after the introduction of Invisalign. At that time, Align Technology suggested successful Invisalign treatment should be limited to relatively minor crowding and excessive space cases.


Diagnosis
The patient presented with a challenging combination of circumstances: severe crowding, narrow upper and lower dental arches positioned to the fullest extent of the supporting skeletal bases, large teeth and a dolichocephalic Class I relation (Figs. 2-6). She was missing the lower left and upper right third molars, but the upper left and lower right third molars were unerupted. The health and status of the gingiva and underlying bone level was excellent and the soft tissue profile good (Figs. 7&8).

Treatment
A quadhelix expansion appliance (.036 stainless steel wire attached to upper first molar bands) was inserted in March 2002, and remained in place for six months until September 2002 (Figs. 9-13). At that time, PVS impressions were submitted to Align Technology where a ClinCheck was created according to the prescribed treatment plan (Figs. 14-16 & 25-29). The first of 25 upper aligners and 13 lower aligners were delivered in October 2002. Around October 2003, at stage 18, 13 upper mid-course correction aligners were ordered (lower correction having been accomplished, patient was continuing to wear lower aligner #13). In January 2004, the clear aligners were discontinued so the patient could begin to wear upper and lower Hawley retainers; four and a half years later, in August 2008, the patient was dismissed from our supervision, although we granted her request to continue to wear her retainers to bed a couple of nights per week (Figs. 18-24).



Discussion
There have been many published articles arguing the efficacy (and even possibility) of expanding the adult, non-growing maxilla. The threat of blowing the teeth out beyond the limits of the alveolar process with excessive forces, resulting in periodontal recession and instability, is certainly a valid concern. As a mentee of Dr. Robert Ricketts, I am a disciple of the biology-friendly light, continuous force paradigm. It is this paradigm that explains the successful expansion of the adult maxilla: the use of light, continuous pressure on the maxillary teeth results in a biological remodeling of the alveolar process as the teeth move buccally. Simply, the quadhelix translates the alveolar process laterally, keeping the teeth well-surrounded by bone and providing adequate attachment for the gingiva. As demonstrated in this patient’s treatment, her expansion was significant, resulted in healthy bone and gingiva and has remained stable for many years.

Although contemporary Invisalign treatment has overwhelmingly dispelled doubts that clear aligners can adequately move teeth and properly align roots, early in the Invisalign experience those doubts were purported by many orthodontists. The appropriately trained Invisalign orthodontist appreciates the importance of judicial use of attachments and staging to move teeth with preferred results. This patient’s treatment validates teeth, even when closing extraction spaces, can be moved and properly aligned with clear aligner therapy (Fig. 24).

The total treatment time for this patient’s correction was 21 months, six months with a quadhelix prior to 15 months of clear aligners, which included 13 mid-course correction aligners for a total of 31 upper and 13 lower aligners. This treatment period strongly suggests use of clear aligners does not prolong the typical treatment time for most corrections and, in fact, often shortens some treatment corrections.

The Invisalign appliance gave this patient the smile and appearance she desired because, she admits, she would not have had orthodontic treatment without that option available. The use of the clear aligners has expanded in today’s orthodontic practice largely due to successful treatment results like this case. The treatment plans are more sophisticated, the attachments are more technologically engineered and the plastic materials are more enduring. Patient demand continues to push orthodontists into becoming Invisalign-trained and providing clear aligners for more types of corrections. If they don’t, the public will simply go elsewhere for treatment.
Author’s Bio
Dr. Ken Fischer graduated from UMKC for dentistry and UCLA for orthodontics. He is in private practice but devotes considerable time to education and professional service to orthodontics. He has been published in several orthodontic publications and is the forensic odontologist for the Orange County Sheriff's Department. Dr. Fischer is an original member of the Align Alpha Group and is on the Clinical Advisory Board. He is also a member of the Orthotown Magazine Editorial Advisory Board.
Orthotown Magazine
September 2025
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