Townie Treatment Case: TADs, Clear Aligners and Overkill by Dr. Bill Dischinger

Categories: Orthodontics;
Orthotown Magazine 

After seeing fantastic progress in a gummy-smile case, this Townie wanted to get things absolutely perfect … but burned out his patient in the process

by Dr. Bill Dischinger

We’ve all seen the amazing transformations that can be achieved using TAD-supported intrusion to solve excessive gingival display (gummy smile). For about 15 years, this treatment has allowed orthodontists to change smiles for which surgery was not an option, either out of the patient’s financial restrictions or their general unwillingness to undergo surgery.

Although the results achieved with temporary anchorage devices (TADs) are remarkable, the mechanics can be complicated and sometimes overwhelming for clinicians to attempt. I can speak from experience that many cases achieved beautiful results, but when looking back on the treatment, the patient and I sometimes wondered if we would do that again.

Many years ago, Dr. Bob Boyd, former chairman of the University of Pacific Department of Orthodontics, presented open-bite cases treated with clear aligners, hypothesizing that these cases were actually easier to treat with aligners than with braces. Despite my great respect and admiration for his work, I remained skeptical—but in 2019, I started an anterior open-bite case with Spark clear aligners and TADs. When I finished the case in 2020, I sent a message to Dr. Boyd, telling him he had been right all along and as a skeptic, I had been judgmental rather than curious. The success of this case prompted me to be bolder in expanding my clear aligner cases to incorporate more difficult cases such as gummy-smile cases. I’d like to present one early gummy-smile case here.

No surgery, no braces … no problem
Michelle, the parent of a patient I was treating, had been coming in for about a year with her daughter and at one appointment approached me with a question regarding her own teeth. She smiled, then told me her gummy smile had always bothered her but she’d always been told she needed orthognathic surgery to fix it.

She had seen on our office Instagram page we had successfully treated a patient similar to her without surgery—more on that later—and wanted to know if I could do the same for her. I immediately told her we absolutely could and explained how we used TADs for this process. She was excited, but then dropped the caveat on me that she would start treatment only if she didn’t need to wear braces and could be treated with clear aligners. Thankfully, I had treated some open-bite cases and sort of knew what to do.

After Michelle left, I asked my team which patient they had posted on Instagram showing the gummy-smile transformation. They pulled it up, and it was one of Dr. Stuart Frost’s patients they had reposted on our page. So … that’s great. I told them we couldn’t do that and immediately called Dr. Frost. He had a big laugh over it and I let him know the referral thank-you gift was in the mail.
TADs clear aligner case
Fig. 1
TADs clear aligner case
Fig. 2
TADs clear aligner case
Fig. 3

Case presentation
As you can see in Michelle’s case (Figs. 1–3), there’s some mild to moderate overbite but other than that, orthodontically she’s in a relatively good position. If she didn’t have the gummy-smile concern, she would not be seeking treatment and certainly wouldn’t need treatment.

One concern when treating cases in which we will be doing significant maxillary impaction movements is the autorotation that will occur with the mandible. Michelle being Class I raised that concern. She did have some overjet, and with a little bit of leveling of the lower arch, I wasn’t very concerned, but it was on my watch list. If I begin to see some Class III developing during the mandibular rotation process, I’ll have patients wear Class III elastics. Most cases don’t need this unless they have a Class III tendency to begin with or are more of a high-angle case. In Michelle’s case, we never needed to worry about this because she did not rotate forward from Class I.

In my initial setup with Spark clear aligners, I programmed 4 mm of full-arch intrusion of the maxillary teeth. I did not perform many other movements, other than a slight uprighting of the 4s and 5s with some buccal crown torque. You will see in the maxillary occlusal photo (Fig. 4) that we placed a lingual 3–3 bonded retainer with retanium wire from Reliance Orthodontics. This is very important. I like to pull from the TADs to just the canines for my anterior intrusion movements and I have found through unfortunate experience that if you don’t lock the 3–3 together as one unit, the canines will intrude quite quickly but the 2–2 lags behind. (You will see the canines have a significant gap of the cusp tip in the aligner, while the 2–2 looks perfectly seated.)

TADs clear aligner case
Fig. 4

Why is this a problem? Once this happens, your patient comes in and the 3s through 7s have all intruded nicely and at a fast rate. The 2–2 has lagged behind, though, and that’s not a very good look. If you then pull from the laterals, thinking surely the centrals will follow … well, you end up with the 2s through 7s intruded 3–4 mm, with the centrals only intruded about 1 mm. (It’s not a very good look. I can tell you from experience—I learned my lesson the hard way.)

Luckily for Michelle, she was not the first patient I was going to treat this way, so she benefited from my learning curve and some discussions with Dr. Trevor Nichols, who was trying out some Spark gummy-smile cases as well. Some orthodontists will place lingual buttons on the 2s and 3s and do lasso elastics from the buttons up to the TADs between the 2s and 3s. In cases such as Michelle’s, I worry about debonding the buttons because of the deep bite. The lingual wire can of course debond as well, but it tends to hold up better than the buttons.

It’s important to instruct the technicians that the lingual bonded retainer will remain in place and there can be no movements of the 3–3 other than intrusion. In our office, we will scan the patient, print a maxillary model and prebend the retanium wire. We will fix the wire to the printed model and scan the model, and use that STL for the maxillary arch submission. The other method is to have the patient back in the office, place the retanium wire and then rescan the maxillary arch. By scanning the model instead, this saves an appointment in the office.

At delivery, I placed four Vector TAS TADs from Ormco—two in the zygomatic arch and two between the laterals and the canines. I prefer 10 mm screws for the zygomatic, rather than 12 mm or 14 mm. For the anterior, I use 8 mm. We bonded buttons on the 3s–7s. I had the patient wear a large triangle elastic in the posterior, under all the buttons from the 4s to the 7s and up to the zygomatic TADs. I personally don’t like to go heavier than 4.5 ounces of force when directly pulling off a TAD. For the anterior, I like to use power chain from the TADs to the buttons on the 3s. I have tried various sizes of elastics, but have not found one that is small enough yet strong enough to work in that area very well. The downside of using power chain is that we need to see the patient in the office every four to six weeks to activate, rather than just remote monitoring them with DentalMonitoring the whole time (Figs. 5 and 6).

TADs clear aligner case
Fig. 5
TADs clear aligner case
Fig. 6

The treatment process
After five months, as you can see, the change is quite remarkable (Fig. 7). When Michelle came in to have a refinement scan taken, she was ecstatic with the change.

This is one of many reasons I prefer to use clear aligners when doing TAD-assisted impaction: We can begin the vertical impaction the first day of treatment. Typically with braces, we need to wait until we have reached a certain size of wire before we can begin using TAD-assisted intrusion. Being able to address the patient’s chief concern on Day One is certainly a great service, and clear aligners allow me to do this in these types of cases. Additionally, clear aligners help us avoid unwanted side effects as we intrude.

In brackets, we have to work hard to avoid unnecessary tipping or loss of torque control during the vertical movement. We have to use a transpalatal arch, place torque in the wire or use other techniques that have been developed over the years. With clear aligners, I don’t overengineer the torque while intruding. Fully covering all surfaces of the crowns controls this for me.

At the scan for Michelle’s refinement aligners, I performed a laser frenectomy and gingivectomy (Figs. 8 and 9.) I use the Spectralase 980 laser from Spectrum Lasers.

Eighteen days after laser treatment and the refinement scan, we delivered the patient’s new aligners and checked the healing process. The progress at just 5.5 months is truly remarkable: We had essentially solved her gummy smile already (Figs. 10 and 11).

After nine months, Michelle had finished the third set of aligners. We removed her TADs and took a scan (Figs. 12–16) for more refinement aligners. At this appointment, the patient told me she was completely satisfied with her smile and wanted to be done with treatment. Being the Type A orthodontist I am, I told her there were a few small details I wanted to perfect, specifically the torque on the upper left canine. She begrudgingly agreed to do some more aligners.

TADs clear aligner case
Fig. 7
TADs clear aligner case
Fig. 8
TADs clear aligner case
Fig. 9

TADs clear aligner case
Fig. 10
TADs clear aligner case
Fig. 11

TADs clear aligner case
Fig. 12
TADs clear aligner case
Fig. 13

TADs clear aligner case
Fig. 14
TADs clear aligner case
Fig. 15
TADs clear aligner case
Fig. 16

The beginning of the end

I should have listened to her at this appointment. Michelle was in a very good place; she was happy, her occlusion was in a healthy position and she had lost motivation to continue treatment. From this point forward, Michelle struggled to wear the aligners as needed.

Since this case, I have begun listening better to my patients, particularly adult patients. When they have gotten to a satisfactory position, if they’re happy and tell me they’d like to be done, I now end treatment at that point as long as the occlusion is in a healthy position and ending treatment at that point will not lead to any long-term issues.

As orthodontists, we always see some small, minor thing we can tweak or perfect. We are not 100% satisfied, but in doing that, many times we will burn out our patients. I burned out Michelle. I treated her for six more months trying to perfect those tiny little details only I could see. She struggled with wearing the aligners, and at 15 months (Figs. 17–24), I realized we weren’t going to get any better than we had been at nine months.

Michelle’s case was a great learning experience for me. I learned how to properly treat gummy smiles in a very efficient and predictable way. I saw the advantage that clear aligners gave us with these cases. I also learned how to listen to my patients and work with them to meet their goals not just for their teeth, but for their lifestyles.
TADs clear aligner case
Fig. 17
TADs clear aligner case
Fig. 18
TADs clear aligner case
Fig. 19

TADs clear aligner case
Fig. 20
TADs clear aligner case
Fig. 21

TADs clear aligner case
Fig. 22
TADs clear aligner case
Fig. 23
TADs clear aligner case
Fig. 24

Author Bio
Dr. Bill Dischinger Dr. Bill Dischinger earned a degree from the Oregon Health & Science University School of Dentistry and a certificate in orthodontics at Tufts University in Boston. Dischinger, an adjunct professor in the orthodontics department at the University of the Pacific in San Francisco, has lectured nationally and internationally on subjects including functional jaw orthopedics, Spark clear aligners, passive self-ligation and practice management. Dischinger is also a member of the American Association of Orthodontists, the Pacific Coast Society of Orthodontists and the American Dental Association.

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