Science in Every Smile SUCCESSFUL TREATMENT OF AN ADULT PATIENT WITH CLASS III MALOCCLUSION AND OPEN BITE USING THE INVISALIGN SYSTEM DR SARAH LAWRENCE BDS (Otago), MDSc (Melbourne) CASE REPORT This case report is intended for dental and healthcare professionals, and is subject to applicable local laws, regulations and guidelines. INVISALIGN, CLINCHECK, and ITERO ELEMENT, among others, are trademarks and/or service marks of Align Technology, Inc. or one of its subsidiaries or affiliated companies and may be registered in the U.S. and/or other countries.
Transcript
Science in Every Smile
SUCCESSFUL TREATMENT OF AN ADULT PATIENT WITH CLASS III MALOCCLUSION AND OPEN BITE USING THE INVISALIGN SYSTEM
DR SARAH LAWRENCEBDS (Otago), MDSc (Melbourne)
CASE REPORT
This case report is intended for dental and healthcare professionals, and is subject to applicable local laws, regulations and guidelines.
INVISALIGN, CLINCHECK, and ITERO ELEMENT, among others, are trademarks and/or service marks of Align Technology, Inc. or one of its subsidiaries or affiliated companies and may be registered in the U.S. and/or other countries.
Attachments – for extrusion upper 2-2 • Optimised Root Control Attachments • Conventional attachmentsFirst refinement: • Optimised Root Control Attachments –
for detailed finishing • Conventional attachments – for active
extrusion buccal teeth Second refinement: • Optimised Root Control Attachments • Optimised Rotation Attachments • Optimised Deep Bite Extrusion
Attachments – to help extrude lower premolars
• Power Ridges – for anterior root torque
Retention• Nightly upper and lower Vivera retainers
TREATMENT OUTCOME
The result for ZK is pleasing both occlusally and aesthetically. The patient is extremely happy since his chief complaint of having an uneven smile was addressed without orthognathic surgery. After the last refinement, the patient stated that his “bite felt just right”. The patient is a good gauge (as well as the use of articulating paper) as to when you have achieved even occlusal contacts.
ZK was highly motivated throughout the entire treatment. He wore elastics consistently throughout the treatment. This coupled with excellent aligner wear resulted in a successful
ZK was a 34-year-old male who presented for an orthodontic consultation. ZK’s presenting complaint was an uneven smile. During a previous orthodontic consultation elsewhere he was recommended fixed appliances in combination with bimaxillary orthognathic surgery for the Class III facial asymmetry. At the age of 10 years old, he underwent maxillary expansion with a rapid palatal expander.
CLINICAL FINDINGS
• Class III molar and canine relationship on right side
• Class I molar and canine relationship on left side
• –1 mm overjet
• 0 mm overbite
• Anterior crossbite
• Spacing present in upper and lower arches
• Lack of incisal display and reverse smile
• 1.5 mm lower midline discrepancy to left
• Mandibular asymmetry – chin point to left
TREATMENT GOALS
• To provide a positive overjet and overbite
• To extrude upper anterior teeth to improve incisal display and smile line
• To camouflage Class III malocclusion and mandibular asymmetry using Class III elastics and interproximal reduction (IPR) as required to avoid orthognathic surgery
• To utilise Invisalign aligners to control the vertical dimension by occlusal coverage to avoid inadvertent bite opening anteriorly while precisely controlling the angulations of the anterior teeth
TREATMENT APPROACH
In this case, the Class III anterior open bite was corrected by a combination of absolute active extrusion of the upper anterior teeth as well as incisor proclination. Retraction of lower anterior teeth using existing space as well as space gained by performing IPR and Class III elastic wear contributed to the correction of the anterior open bite. The patient was advised that the lower midline discrepancy may not be corrected due to the mandibular asymmetry, but the aim in the initial ClinCheck Plan was to correct this using Class III elastics. The aligners were changed every 2 weeks and the Class III elastics were commenced at aligner no. 6 in the initial ClinCheck Plan. The elastics were run off elastic cut outs on the lower first premolars to buttons on the upper 7s (button cut-outs were placed on upper second molars). The elastics used were 3/16” (3.5 oz).
At the end of the first series of aligners some small issues with alignment were present, as well as lack of posterior contact due to anterior interferences. The lower midline was still non-coincident with the upper. The aim of the first refinement (additional aligners number 1) was to align the arches further, retract the lower anterior teeth, and correct
Science in Every Smile
CLINICAL PRESENTATION
ZK presented with a Class III
skeletal malocclusion, anterior
open-bite tendency with
mandibular asymmetry and lower
dental midline discrepancy.FIGURE 1. INTRA- AND EXTRA-ORAL IMAGES BEFORE TREATMENT
FIGURE 2. PANORAMIC RADIOGRAPH BEFORE TREATMENTFIGURE 3. CEPHALOMETRIC RADIOGRAPH BEFORE TREATMENT
the lower midline with IPR. The upper and lower buccal segments were actively extruded to help to improve occlusal interdigitation. Class III elastics were continued throughout the refinement.
At the conclusion of the first refinement, the upper and lower midlines were essentially coincident and the bite and buccal occlusion had improved, but there were still some anterior interferences and the buccal occlusion was still open. The second and final refinement (additional refinement number 2), aimed to further procline the upper incisors and again actively extrude the posterior buccal teeth. Elastic cut-outs were placed and elastics continued through to refinement number 2. As G5 advancements were introduced by Align Technology, Inc. at this time, G5 Optimised Attachments were used in the lower arch to help to extrude the lower premolars to improve occlusal contact with the upper premolars.
TREATMENT DETAILS
Active Treatment Time22 months.
Aligners UsedInitial stage:
• 24 upper aligners
• 24 lower aligners
First refinement:
• 9 upper and lower aligners
Second refinement:
• 15 upper and lower aligners
PRE-TREATMENT
FIGURE 4. INITIAL CLINCHECK IMAGES
FIGURE 5. FINAL CLINCHECK IMAGES
This case report is intended for dental and healthcare professionals, and is subject to applicable local laws, regulations and guidelines.
INVISALIGN, CLINCHECK, and ITERO ELEMENT, among others, are trademarks and/or service marks of Align Technology, Inc. or one of its subsidiaries or affiliated companies and may be registered in the U.S. and/or other countries.
This case report is intended for dental and healthcare professionals, and is subject to applicable local laws, regulations and guidelines.
INVISALIGN, CLINCHECK, and ITERO ELEMENT, among others, are trademarks and/or service marks of Align Technology, Inc. or one of its subsidiaries or affiliated companies and may be registered in the U.S. and/or other countries.
Science in Every Smile
anterior teeth is not fully corrected then an anterior interference can result, which can present clinically as a posterior open bite. The practitioner should check the bite with articulating paper at the end of the treatment. It is also recommended to take photos to see clearly where the interference lies to ensure that this is addressed in the ClinCheck Plan. In the second refinement for ZK, the proclination of the upper incisors on the ClinCheck Plan was accentuated, which can look odd digitally. This over-correction in the ClinCheck Plan is not reflected clinically and is in place to accommodate for tooth movement lag.
CONCLUSION
The patient presented with a Class III, open-bite malocclusion with an underlying mandibular asymmetry. This case could be treated with orthognathic surgery to improve the retrusive maxilla and mandibular asymmetry; however, it was effectively treated with the Invisalign appliance alone. Optimised Multi-plane Extrusion Attachments were used to effectively extrude the upper anterior teeth, which improved the overbite and also created a more harmonious smile line. Elastics were utilised during treatment to help with Class III correction and to improve
outcome. He is currently in retention in upper and lower Vivera retainers and the occlusion remains stable. I anticipate that the Vivera retainers will hold the correction well, particularly the vertical component due to the nightly occlusal coverage.
Clinical Tips• The Invisalign appliance, in my opinion,
is the ultimate technique for correcting a Class III, open-bite malocclusion. This is because of the vertical control both through occlusal coverage by the aligners, which avoids inadvertent posterior extrusion, as well as active extrusion of the upper incisors (aided by Optimised Multi-tooth Extrusion Attachments). The appliance also helped to precisely correct the anterior-posterior dimension by keeping the lower incisors retroclined and proclining the upper incisors. The addition of the Class III elastics in combination with IPR also aided in the correction of the lower midline discrepancy.
• Upon review of the case, to improve efficiencies in treatment, I would add more proclination to the upper incisors in the initial aligner phase. Often when correcting a Class III malocclusion, if the torque of the
FIGURE 6. PANORAMIC RADIOGRAPH AFTER TREATMENT
FIGURE 7. CEPHALOMETRIC RADIOGRAPH AFTER TREATMENT
POST-TREATMENT
FIGURE 8. INTRA- AND EXTRA-ORAL IMAGES AFTER TREATMENT
the lower asymmetry in combination with IPR.
The final photos and radiographs show ZK to still have a Class III skeletal pattern with a mandibular asymmetry. His teeth have compensations that have been created to help camouflage the discrepancy. The upper incisors have been proclined, and the lower incisors retroclined. Despite this, ZK has achieved a great aesthetic outcome and an excellent functional result.
Author disclosureDr Sarah Lawrence was provided an honorarium from Align Technology, Inc., for her contribution towards the creation of this case report.
Dr Sarah Lawrence Sarah Lawrence originally grew up in New Zealand and graduated from the University of Otago, New Zealand with a bachelor’s degree in Dental Surgery (with honours). Upon graduation, Dr Lawrence worked in private and hospital practice as a General Dentist. She spent 2 years in the United Kingdom as a Senior House Officer in Oral and Maxillofacial Surgery. Returning to Australia, Dr Lawrence completed her 3-year specialist orthodontic training at the University of Melbourne, Australia. Dr Lawrence has previously worked at the Royal Children’s Hospital, Melbourne in the Craniofacial Unit. She is in private orthodontic practice in partnership with her husband, Dr Igor Lavrin. She is a Clinical Tutor for postgraduate orthodontic students at the University of Melbourne. She has a keen interest in Invisalign treatment and has been using the Invisalign appliance for over 10 years. Dr Lawrence co-presented at the 2015 ANZ Invisalign Orthodontic Forum, Queenstown, New Zealand. She was also a co-speaker for Orthodontic Invisalign Masterclasses in ANZ and is a current Future Elite NZ speaker for 2016.
This case report is intended for dental and healthcare professionals, and is subject to applicable local laws, regulations and guidelines.
INVISALIGN, CLINCHECK, and ITERO ELEMENT, among others, are trademarks and/or service marks of Align Technology, Inc. or one of its subsidiaries or affiliated companies and may be registered in the U.S. and/or other countries.
