WINTER 2015 The Academy for Clear Aligner Therapy Journal the American Academy of Cosmetic Orthodontics To receive this quarterly journal, register at www.aacortho.com ISSN 2372-0808 (Print); ISSN 2372-0816 (Online) The Bible on Fixing IATROGENIC POSTERIOR OPEN BITE Page 6 Case Reports Clear Aligner Treatment with Conservative Composite Restorations Page 4 Innovative Techniques The Thermoplastic Pontic Appliance Page 14 From the Hygiene Chair The Importance of a Complete Medical History in Orthodontic Treatment Planning Page 22
Transcript
W I N T E R 2 0 1 5
The Academy for Clear Aligner TherapyJournalthe
American Academy of Cosmetic Orthodontics
To receive this quarterly journal, register at www.aacortho.com
ISSN 2372-0808 (Print); ISSN 2372-0816 (Online)
The Bible on Fixing IATROGENIC POSTERIOR OPEN BITE Page 6
Case Reports Clear Aligner Treatment with Conservative Composite RestorationsPage 4
Innovative Techniques The Thermoplastic Pontic AppliancePage 14
From the Hygiene Chair The Importance of a Complete Medical History in Orthodontic Treatment Planning Page 22
Case Reports4 Clear Aligner Treatment with
Conservative Composite Restorations by Robert Leach, DDS
Innovative Techniques14 The Thermoplastic Pontic Appliance by Perry E. Jones, DDS, MAGD
Perspectives from the Hygiene Chair22 The Importance of a Complete Medical History
in Orthodontic Treatment Planning by Joycelyn A. Dillon, RDH, MA
Product Review 24 The Outie Tool by Nadine Saubers, RN
2015 Winter Buyer’s Guide 26 Advertising Section
Viewpoint 32 Thank God It’s a Root Canal! by Jeffrey M. Galler, DDS
Feature Article 6 A Clinician’s Guide to Reducing
the Occurrence of Posterior Open Bite following Clear Aligner Therapy
by Mark Hodge, DMD
Article is Peer Reviewed Article offers CE Credit at www.aacortho.com
Journalthe
American Academy of Cosmetic Orthodontics
Did You Know?Renewal of your annual AACO membership is ONLY $99. Log on to aacortho.com for new features and learning opportunities, and to renew your membership.
Special pull-out section, suitable for chair-side reference.(see centerfold)
6 the Journal: winter 2015
FeatureArticle
A Clinician’s Guide to Reducing the Occurrence of Posterior Open Bite following Clear Aligner Therapy by Mark Hodge, DMD
The desired end result of every orthodontic case is an improved, balanced occlusion with all teeth touching. However, when treating a patient’s malocclusion using Clear Aligner Therapy, clinicians frequently report seeing a resultant iatrogenic malocclusion that they classify as “posterior open bite.”
A posterior open bite, as an unintended consequence of Clear Aligner Therapy, is a fairly common obstacle in achieving the end goal of a balanced occlusion. A review of the literature, blog posts, and online CE courses paints a picture of posterior open bite being a somewhat random “sequela” of having the occlusal surfaces of teeth covered by two layers of plastic during the course of orthodontic treatment. According to this
model, the masticatory forces applied to dentition that has had its vertical dimension temporarily increased by the thickness of the clear aligners can cause an intrusion of posterior teeth, thereby creating a posterior open bite.
While intrusion of posterior teeth can occur and can be considered the chief etiology of some posterior open bites, it would be oversimplistic to see this as the sole cause. It is beyond the scope of this article to address every possible reason for a patient’s having a posterior open bite at the end of Clear Aligner Therapy. However, in my opinion after an extensive review of over 5000 Invisalign ClinChecks, posterior open bite (POB) at the end of treatment can be attributed to four main etiologies:1. Intrusion of posterior teeth during treatment2. Failure to recognize maxillary tooth size discrepancy3. Development of a ClinCheck with tight overjet4. Correction (uprighting) of lingually inclined upper
anteriors, followed by retraction of the anteriors, in the same ClinCheck
Effective prevention and treatment of posterior open bite (POB) will vary based upon the etiology of the new malocclusion.
The purpose of this article is to equip the clinician with the tools necessary to • reduce the occurrence of POB,• recognize potential etiologies of POB, and• effectively treat POB once the etiology has been diagnosed.
Each of the four dominant etiologies will be discussed, to help make your future cases more predictable and, hopefully, reduce the occurrence of POB in your practice. The discussion of each potential etiology will be accompanied by tips for correcting a POB that was caused by that etiology. Each section will conclude with recommended actions that the clinician can take to prevent the POB from developing in the first place.
Dr. Mark Hodge attended the Michael Cardone, Sr. School of Dentistry at Oral Roberts University and received his DMD in 1985. Since graduation, he has served on the faculty of two dental schools: Oral Roberts University and Loma Linda University. Dr. Hodge is a founding partner
of Berkshire Dental Group in Tulsa, Oklahoma, and currently serves as a clinical director for Heartland Dental Care.
Dr. Hodge’s passion for creating great smiles with optimal function led him naturally to cosmetic orthodontics. Since completing his training to offer Invisalign®, he has become one of the leading providers in the country, and now serves as vice president of the American Academy of Cosmetic Orthodontics. He is a nationally recognized speaker on topics including patient communications, team engagement, and the clinical skills required for mastering the Invisalign technique, and is featured in multiple Invisalign-related videos and educational resources.
7the Academy for Clear Aligner Therapy
Scenario 1Posterior Open Bite via Intrusion of PosteriorsAligners are flexible, and when patients clench against them, they can intrude posterior teeth by an amount equal to the thickness of two aligners. The amount of POB is the best visual test to confirm etiology. If the POB is only about 1.0 mm to 1.5 mm, then it may be the result of intrusion. If the POB is more than 1.5 mm, you should assume that other factors are at play, and resolving the POB will require a different approach from what is recommended here.
Treatment to correctThe first question is: Are all other tooth movements correct, so that POB is the only thing keeping the case from being complete? If so, proceed with the recommendations below.
If other movements (rotations, extrusions, etc.) are still needed, polish off attachments and do a refinement. In the refinement, specify: “Close posterior open bite by extruding posteriors and resolving anterior interferences.”
If POB is the only remaining movementOnce the patient has completed wear of his or her final active aligner, trim one (or both) of the aligners, distal to the last tooth that has occlusal contact. If all posterior teeth are open, trim just distal to the canines. If only molars and second bicuspids are open, trim distal to the first bicuspid. If POB is unilateral, trim only the aligners on the side with the POB.
Trimming the aligners allows for passive eruption of the posterior teeth. Passive eruption usually takes a minimum of 6 weeks before progress is visible. To gauge your progress, when you trim the aligners, also take a segmental bite registration over the POB segments, and store it until the next appointment. At your first post-trimming observation visit, reinsert the bite registration over the posterior teeth. If posterior teeth are extruding, then the patient will have an anterior open bite when he or she closes against the previous bite registration.
Even though posterior movements may have completed earlier in treatment, do not trim the aligners until after the patient has completed the two weeks of wear in the final aligner. Full posterior coverage during the two weeks that each active appliance is to be worn provides the anchorage necessary for the remaining anterior movements to occur. Premature trimming of the aligners could reduce your anterior finish.
The potential of developing POB is one reason our recommended treatment preferences include overcorrection aligners on all cases. Overcorrection aligners can help you treat POB.
If there is surplus spaceConventionally, overcorrection (OC) aligners are only indicated to be dispensed in one situation: surplus space between anteriors at end of treatment. OC aligners are designed to act like a virtual “C-chain” to pull the anteriors closer together.
That is all they do. If there is no space at end of treatment, don’t use them. If the OC aligners put pressure on the anteriors and there is no space to close, they can cause unintended intrusion.
(Since OC aligners are free, we recommend requesting them on every ClinCheck, in case you finish with surplus space due to incomplete movement or too much IPR. On the ClinCheck timeline, OC aligners are shown in a salmon (or brownish) color stage. Active aligners are blue, and passive aligners are grey; (see below).
An alternate technique using OC alignersAlthough OC aligners are designed to close surplus space, they can also help solve POB caused by intrusion. Let’s assume the patient has finished wear of the active aligners with no surplus space, but anterior heavy occlusion (i.e., POB). First, trim the upper aligner to uncover the posterior teeth that aren’t in occlusion. Then, use coarse polishing strips to create space between the lower anterior teeth; finally, dispense only lower OC aligners to close the new spaces. As the OC aligners move the lower anteriors lingually, the heavy anterior occlusion will lessen and the vertical dimension will close. The patient should wear the shortened upper aligner while progressing through the lower OC aligners.
Whenever they are used, OC aligners should be dispensed one at a time and checked every 2 weeks. Dispense the next OC aligner only if there is still interproximal space present, or if you wish to repeat the process by creating more interproximal space and then using the OC aligners to close the space and further correct the posterior open bite.
In addition, in order to further lessen the heavy anterior occlusion, don’t be bashful about contouring the lingual of upper incisors with a football-shaped bur and smoothing the incisal edges of lower anteriors. I recommend evaluating every case for enamelplasty at the end of orthodontia. Finishing a case with minor occlusal equilibration and cosmetic recontouring will make the case more stable and more esthetic. In addition, this enamelplasty may simplify the correction of any POB.
If the posterior teeth do not extrude as needed via passive eruption, extrusion can be facilitated with refinement aligners or the use of bonded buttons and elastics. More information on extrusion with elastics can be found in this webinar: https://learn.invisalign.com/ce_sessions/archived/20
Prevention of POB via intrusionIntrusion is not inevitable yet is fairly predictable in patients who are heavy clenchers. Intrusion is more common in cases that extend beyond 23 aligners in duration. Posterior intrusion will be less if your clinical preferences are set to our recommended clinical preferences (see page 13), since the preferences are designed to help facilitate shorter cases.
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One preventive measure is to trim passive aligners 4 to 6 weeks after active movement in the arch ceases. Passive aligners allow for both arches to finish simultaneously. However, their use increases the length of time that the posterior teeth are covered by two layers of plastic. Once one arch enters the passive phase, consider trimming the passive aligners after the second or third passive aligner. This will enable the shortened passive aligners to retain the anterior teeth yet allow for passive eruption of the posterior teeth in that arch.
Patients who are clenchers often have little overjet and/or a deep bite. Bite ramps, applied to the lingual of the upper anteriors, will help to keep the intruding forces of the occlusion off the posterior teeth. More information on use of bite ramps is available online using the following link: https://learn.invisalign.com/ce_sessions/archived/559
Because posterior intrusion is unpredictable, it is not always possible to prevent it. However, POB caused by intrusion is relatively easy to correct.
Scenario 2Posterior Open Bite via Tooth Size DiscrepancyDental research estimates that tooth size discrepancy (TSD) occurs within 22.9%-37.9% of the population (depending upon the study and the population sample being considered). TSD should always be considered in cases where there are dissimilar arch issues, such as spacing over crowding, or mild crowding over heavy crowding.
The most frequent TSD is undersized maxillary lateral incisors. While the golden proportion of smile design relates to the visual display of teeth, statistical norms for the actual measurements of teeth indicate that an upper lateral incisor should be (at minimum) approximately 65% of the width of the central incisor (Figure 1).
If the presence of undersized lateral incisors goes undetected and treatment consists of closing all space, then the envelope of function will be constricted. This results in the case finishing with heavy anterior occlusion and a posterior open bite.
Treatment to correctA case with a constricted envelope of function is very prone to relapse. Resolving the POB entails correcting the heavy anterior occlusion by creating a set of refinement aligners.
Ideal resolution uses refinement aligners to procline the upper anteriors and create residual space distal to the lateral incisors. The laterals are then restored to proper width and morphology via veneers or bonding. Obviously, it may be difficult to address the prospect of additional treatment and expense with the patient at this stage if it wasn’t discussed initially.
If restoring the laterals is not a viable option, then the refinement will consist of creating upper anterior lingual root torque, lower anterior IPR, and/or intrusion of the lower anteriors.
Prevention of POB via tooth size discrepancyThe best way to prevent POB via tooth size discrepancy is to assume every case has a TSD until you rule it out. This will allow you to have a pre-treatment conversation with the patient about the need to restore the laterals after the orthodontics are complete. My experience is that about 50% of the patients understand the need/benefit and elect the combination orthodontic/restorative option. The remaining 50% choose an orthodontic-only option and accept that moderate to significant lower IPR will be necessary.
If patient elects the combination orthodontic/restorative option, use the following tip when developing your ClinCheck: Once you have your ClinCheck set to accomplish all your orthodontic goals, request 1 final modification prior to approving the ClinCheck. Make the following request: “Please provide 1 additional stage to the upper treatment and place virtual pontics of ideal width and morphology over teeth #7 and #10.”
This will give you a “digital wax-up” of a simulated veneer, mimicking your overall treatment goals. This “digital wax-up” serves to remind patients that they committed to restorative treatment after the orthodontics and gives them a visual preview of the completed combination treatment. In addition, it will generate an aligner that can be used to help form your temporary when you prep the teeth for veneers (Figure 2).
Scenario 3Posterior Open Bite via Tight Overjet Clear Aligner technicians, by default, focus on aligning the lingual of upper anteriors, as a priority over aligning the facial surfaces of the anteriors. They do this to help avoid irregular
Figure 1: golden proportion of smile design.
9the Academy for Clear Aligner Therapy
or heavy anterior occlusion. However, as a result, your first ClinCheck will sometimes not meet your esthetic criteria. As you modify the ClinCheck, recognize that almost every time you adjust the orientation of the facial of the upper incisors, you are moving the lingual of the upper anteriors toward the facial of the lower incisors, decreasing overjet. Decreased overjet increases the potential of posterior open bite.
Treatment to correctThe most expedient means of correction for POB due to lack of overjet is occlusal adjustment/enamelplasty. Focus on adjusting the bulbous mounds of enamel on the lingual of upper centrals (Figure 3). Also, smooth/shorten/polish the incisal edges
of the lower anteriors. Frequently, the lower anteriors have ragged edges and wear facets, and the patient appreciates the cosmetic enhancement.
As with the case of POB via intrusion in Scenario #1, don’t be bashful about contouring the lingual of upper incisors with a football-shaped bur and smoothing the incisal edges of lower anteriors. Evaluate every case for enamelplasty at the end of orthodontia. Finishing a case with minor occlusal equilibration and cosmetic recontouring will make the case more stable and more esthetic.
Prevention of POB via tight overjetExperience has shown that clinical overjet is often less than overjet shown on the ClinCheck. Steps to take in preventing a case from finishing with tight overjet include
• marking the occlusion with articulating paper when you take your initial Invisalign photos, and
• setting your treatment preferences to request 2.0 mm of overjet.
Marking the occlusion with articulating paper prior to taking your photos will allow you to send those occlusal markings to the technician who develops your ClinCheck. With this information the technician can give you a more accurate bite set, reducing the potential for a tight overjet that causes anterior interferences and POB (Figure 4).
Our recommended clinical preferences include a request to finish with 2.0 mm of overjet. While you may not want that much overjet clinically, requesting it in the ClinCheck reduces the potential for a tight overjet that causes anterior interferences and POB. Most often your case will finish with less overjet in the mouth than what is shown on the ClinCheck.
Figure 2a: peg lateral.
Figure 2b: virtual pontic.
Figure 3: lingual of upper centrals.
Figure 4: mark centric stops with articulating paper prior to Invisalign photos.
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On the rare occasion when you finish with more overjet than desired, a refinement to correct surplus overjet is much easier to do than a refinement with too little overjet and POB.
Scenario 4Posterior Open Bite via Correction of Lingually Inclined Upper Anteriors with Accompanying Retraction When treating cases and evaluating ClinChecks, it is most valuable to think in multiple planes of space and honor the fact that the mandible is simply suspended in space by muscles and ligaments. The ClinCheck software cannot illustrate this dynamic and typically shows a static hinge axis. It is up to the treating doctor to mentally incorporate the dynamics of the joint into the ClinCheck evaluation.
This is of particular importance when treating patients with significantly lingually inclined upper anteriors (Figure 5). Failure to take the dynamics of the joint into consideration on these cases will often yield a case with heavy anterior occlusion and a posterior open bite that is difficult to correct.
For Class II Division 2 cases like this one, I recommend addressing the bulk of the anterior-posterior (AP) correction in refinement, not the first ClinCheck. Here’s the explanation:
The lingual inclination of the upper anteriors has often caused a posterior entrapment of the mandible. As you correct the lingual inclination of the upper anteriors, you can get a passive, postural forward repositioning of the mandible. If you first do a lot of upper IPR on your first Clincheck to reduce the overjet shown with a static hinge axis, and then the mandible relaxes and shifts forward...you’re sunk. This is why many cases finish with anterior-only occlusion. This is particularly common if you attempt to use Invisalign Assist to treat a Class II Division 2 case.
My recommendation is to treat almost all Division 2 cases in 2 stages: First, do a ClinCheck with no (or very conservative) maxillary IPR; then, adjust AP issues in refinement once you can assess the patient’s centric relation without the anterior interferences. Attempting to treat a case with a single ClinCheck when you have a known anterior occlusal interference will always yield a frustrating time trying to finish the case. Use the first ClinCheck to correct the anterior interferences and free up the mandible. Then do a refinement. It is much easier to move progressively and sequentially than to try to undo IPR.
Treatment to correctIf you have a case in which you treated lingually inclined upper anteriors with upper IPR and then finished with heavy anterior occlusion and a posterior open bite, there are steps you can take to address the POB.
First, look to perform any possible occlusal adjustment/ enamelplasty to reduce the anterior interference. Also, look for any needed posterior restorative work that needs to be done that might allow you to restore one arch to an increased
vertical dimension. Next, refinement with lower IPR will most likely be indicated. Additionally, posterior vertical elastics may be needed to extrude the posteriors (Figure 6). Information on posterior extrusion with elastics is discussed in the following webinar: https://learn.invisalign.com/ce_sessions/ archived/20.
Prevention of POB via correction of lingually inclined anteriorsDo not use Invisalign Assist for Class II Division 2 cases, or cases with upper anteriors that have heavy lingual inclination.
Figure 5: lingually inclined upper anteriors.
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You may wish to consider asking more experienced Invisalign providers, or posting a blog question on the American Academy of Cosmetic Orthodontics website, when treating such cases.
When treating Class II Division 2 cases, or cases with upper anteriors that have heavy lingual inclination, use the first ClinCheck to correct the anterior interferences and free up the mandible. Then do a refinement. While the total number of aligners may seem like a lot, most often this approach will yield a shorter treatment time, a happier patient, and a more stable occlusion, compared to attempting to do it all in one ClinCheck and then having to fix a POB with elastics.
ConclusionClear Aligner Therapy is an effective, predictable orthodontic treatment modality and can be reliably used to achieve the stated treatment goal of an improved, balanced occlusion with all teeth touching. While no clinician can achieve 100% success with 100% of his or her cases, posterior open bite need not be the issue that prevents clinicians from reaching their treatment goals. Clinicians can effect a reduction in the occurrence of iatrogenic posterior open bite by: • Accurately diagnosing maxillary tooth size discrepancy and
factoring the discrepancy into the treatment regimen;• Establishing an initial ClinCheck that finishes with excessive
“digital overjet” so that the clinical overjet is adequate; and• Treating Class II Division 2 cases in two stages:
1) Correction of lingually inclined anteriors; and 2) Retracting the anteriors in a refinement series
of aligners. n
Editor’s Note For further information about posterior open bites, readers may wish to refer to these past articles in the Journal of the American Academy of Cosmetic Orthodontics:1. How to Avoid the Dreaded, Iatrogenic Open Posterior Bite,
by Dr. Adam Goodman, AACO Journal, Winter 2013, pages 33-35.
2. How to Treat the Dreaded, Iatrogenic Open Posterior Bite, by Dr. Adam Goodman, AACO Journal, Spring 2013, pages 30-32.
Figure 6: posterior extrusion elastics.
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13the Academy for Clear Aligner Therapy
Allows for an equal number of aligners for both arches on every case. Otherwise one arch finishes early and the patient wears the last aligners for an extended period, creating a hygiene issue and cracked appliances. Passive aligners are not available with Assist.
Allowing IPR and attachments on first visit is a more productive use of chair time. Verbally preheat the patient at the records appointment by saying that “small, tooth-‐colored attachments will be bonded to the teeth to assist with directional movements.” Advise the patient that “some of the crowding may be the result of teeth being too wide to fit into the smile properly, and the computer analysis may determine that a few teeth need to be strategically slenderized to achieve the proper bite.” Call it a “dental manicure.”
Maxillary spacing is often the result of subtle tooth size discrepancy crated by undersized laterals. This preference will give you an initial ClinCheck with canine and centrals properly positioned. If residual space does exist, then you can either modify the ClinCheck with IPR of the opposing arch, or propose veneers or bonding to the patient on the laterals. Look for tooth size discrepancy in the consult phase so that veneer discussion does not come as an afterthought.
Trimming aligners shorter in the presence of gingival recession or large undercuts keeps the aligners from being too retentive.
Virtual C-‐chain creates 3 stages at the end of the ClinCheck that are designed to close any residual anterior spaces. These aligners are nice to have if you accidentally do too much IPR. If you select the virtual C-‐chain, both you and the patient need to know that real tooth movement stops 3 stages before the last stage shown on the ClinCheck, and that the overcorrection aligners are optional and may not be needed. Overcorrection aligners are dispensed one at a time and checked every two weeks to see if residual space has disappeared. If there is no residual space, do NOT use overcorrection aligners; instead proceed either to refinement or retainers.
Dr. Hodge Recommended Clinical Preferences for Invisalign
Choose the numbering system of your preference.
Treatment will be more predictable and less IPR will be needed if maximum expansion is selected.
Since upper lateral incisors often unintentionally intrude during treatment, selecting that they finish even in the ClinCheck will give you a clinical result that puts them 0.5 mm more gingival than the centrals.
22 the Journal: winter 2015
The Importance of a Complete Medical History inOrthodontic Treatment Planning by Joycelyn A. Dillon, RDH, MA
The goal of a treatment plan is to achieve optimal oral health, esthetics, and function for the patient. In treatment planning for a prospective orthodontic patient, there are two primary questions to be addressed: What is the patient’s main concern? And, perhaps even more important, are there any medical contraindications or significant considerations to be mindful of in treatment planning?
The role of the dental hygienist as a co-clinician in treatment planning for the medically compromised orthodontic patient is extremely significant. The patient will ordinarily state his or her main concern upon first arriving, or even when calling to make the first appointment. Nonetheless, an interview with the patient or parent/guardian can provide the clinical team with crucial details about the patient’s present status and the results which he or she wishes to obtain, even before the tools of radiography, photography, and intra- and extraoral examination are brought to bear.
A thorough review of the medical history is, in many respects, the most significant procedure to determine whether there are contraindications or important modifications to the treatment of the particular case. Here again, the hygienist can begin to make determinations regarding treatment contraindications as soon as the patient is sitting in the dental hygiene chair.
Orthodontics is noninvasive, so there are not many contraindications for treatment, yet a thorough assessment can yield valuable and useful information that will guide the treatment plan and ensure the patient’s safety. This paper will present a partial review of some of the diseases and conditions that might be present in a patient seeking orthodontic care, along with recommendations regarding contraindications and treatment modifications by the dentist and dental hygienist for each condition.
The dental hygienist must be knowledgeable regarding commonly occurring conditions and their possible treatment implications. The presence of any of these conditions in the patient’s history should prompt an interview by the hygienist to glean additional details. The hygienist should then highlight the areas of concern, thereby alerting the dentist of the need for special considerations in planning the treatment of the case. A preliminary discussion of findings between the hygienist and the dentist, as well as consultation with the patient’s physician, may be warranted, depending on the seriousness of the condition.
After consideration of the medical history, the dental hygienist should perform an intra- and extraoral examination, documenting findings such as the class of occlusion, parafunctional habits, and soft tissue status. In addition,
Joycelyn Dillon is an Associate Professor and Chair of the Dental Hygiene program at New York City College of Technology. She also practices clinical dental hygiene, and is an extended member of the New York State Board for Dentistry. Passionate about her profession,
Professor Dillon teaches periodontics and clinical dental hygiene. She lectures on a variety of topics and also provides community services.
Perspectives from the Hygiene Chair
Dental hygienists play a key role in making sure that the dental office obtains a complete and comprehensive medical history before initiating any treatment. An often overlooked consideration is the importance of how medical findings can affect an orthodontic treatment plan.
23the Academy for Clear Aligner Therapy
the hygienist should note specific considerations that affect the patient’s dental hygiene care and oral hygiene education.
The tear-out table in the center of this issue of the Journal (also available for download at aacortho.com) comprises a partial list of conditions, medical history findings, and special considerations in dental hygiene and orthodontic treatment planning.
ConclusionCollaborative treatment planning for the medically compromised orthodontic patient begins with the dental hygienist’s thorough review of the medical history. Guided by concern for the patient’s safety during treatment, it defines a trajectory toward optimal health, esthetics, function, and ultimately a satisfied patient and a fulfilled dental team. n
The author thanks Dr. Perry Jones and Dr. Eli Halabi for their invaluable contributions in helping prepare this article.
References
1. Darby ML, Walsh M. Dental Hygiene: Theory and Practice. 1st ed. Philadelphia, PA: Saunders; 1995: chap 29.
2. Burden DJ, Coulter WA, Johnston CD, Mullally B, Stevenson M. The prevalence of bactaeremia and orthodontic treatment procedures. Eur J Orthod. 2004 Aug;26(4):443-447.
3. Burden D, Mullally B, Sandler J. Orthodontic treatment of patients with medical disorders. Eur J Orthod. 2001 Aug;23(4);363-372.
4. Duggal S, Kapoor DN. Orthodontics and medical disorders: Clinical considerations. Orthod Cyber J. 2012 Jul. http://www.orthocjcom/ 2012/07/ orthodonticsandmedical. Accessed September 29, 2014.
5. Patel A, Burden DJ, Sandler J. Medical disorders and orthodontics. J Orthod. 2009 Dec;36:Suppl:1-21. doi: 10.1179/14653120723346.
7. Krishnan V, Davidovitch Z. The effect of drugs on orthodontic tooth movement. Orthod Craniofac Res. 2006 Nov;9(4):163-171.
8. Sonis ST. Orthodontic management of selected medically compromised patients: Cardiac disease, bleeding disorders, and asthma. Semin Orthod. 2004 Dec;10(4):277-280.
9. Fujimiura Y, Kitaura H, Yoshimatsu M, et al. Influence of bisphosphonates on orthodontic tooth movement in mice. Eur J Orthod. 2009 Dec;31(6):572-7. doi: 10.1093/ejo/cjp068.
10. Jones P. Tooth movement and bisphosphonates. J Am Acad Cosmetic Orthod. 2014 Summer:8-10.
11. Zahrowski JJ. Optimizing orthodontic treatment in patients taking bisphosphonates for osteoporosis. Am J Orthod Dentofacial Orthop. 2009 Mar;135(3):361-74. doi: 10.1016/j.ajodo.2008.08.017.
12. Miraglia B. Propel-ing clear aligner treatment time. J Am Acad Cosmetic Orthod. 2013 Summer:26-31.
13. Sheller B, Williams B. Orthodontic management of patients with hematologic malignancies. Am J Orthod Dentofacial Orthop. 1996 Jun;109(6):575-580.
14. American Association of Orthodontists. Tobacco Use and Your Orthodontic Treatment. http://www.aaoinfo.org/system/files/media/documents/Tobacco%20Use-MLMS-13-l.pdf. Accessed September 29, 2014.
*According to the American Dental Association:
Antibiotic prophylaxis recommendations exist for two groups of patients:
• those with heart conditions that may predispose them to infective endocarditis
• those who have a total joint replacement and may be at risk for developing hematogenous infections at the site of the prosthetic
The current recommendations cite that use of preventive antibiotics before certain dental procedures might be useful for patients with:
• artificial heart valves
• a history of infective endocarditis
• a cardiac transplant that develops a heart valve problem
• the following congenital (present from birth) heart conditions:
• unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
• a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
• any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device
**According to Align Technology:
Invisalign® aligners and retainers and Vivera® retainers are made from polyurethane or polyurethane/copolyester. The FDA has approved polyurethanes for use in the human body. Invisalign aligners and retainers and Vivera retainers do not contain latex or Bisphenol A (BPA). Based on Align’s biocompatibility testing, Align has found that some patients may experience symptoms or a reaction to the material, but Align believes the number of these instances is very low. In most cases, symptoms of a patient’s reaction reported from doctors or patients are similar to those experienced with other forms of orthodontic treatment (e.g., soreness of teeth, abrasions or lesions on the gums or mouth, headache, irritated tongue, swelling of oral tissues).
Medical History Orthodontic Concerns
*High Risk for Infective Endocarditis *Total Joint Replacement
• Prophylactic antibiotics might be indicated for procedures likely to cause bleeding,1 such as extractions, Interproximal Reduction (IPR), or fitting and cementing bands or temporary anchorage devices (TADs), as part of the patient’s orthodontic treatment.2
Cardiovascular Disease
• Be aware of possible contraindications to epinephrine in local anesthetics.• Determine if patient is on anticoagulant drugs. • Note that calcium blocker medications might cause gingival hyperemia.• Note that some medications might cause xerostomia.• Avoid long, demanding appointments.3,4,5
Bleeding Disorders
• Patients should not take aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) for discomfort.6,7,8
• Encourage patients to maintain excellent, atraumatic oral hygiene.• Avoid chronic irritation from orthodontic appliances.3,4,5
• Remember that clear aligners can cause gingival irritation. Make sure the aligners are trimmed to avoid impingement on the gingival tissue.
Bisphosphonate Therapy• Orthodontic tooth movement is decreased after bisphosphonate administration.• A harmful and unwanted side effect of bisphosphonate therapy, especially if given IV, can be osteonecrosis.• Inform patients of possible harmful complications.9,10,11
Patients Taking Aspirin or Other Nonsteroidal Anti-inflammatoryMedications (NSAIDs)
• The use of procedures designed to accelerate orthodontic movement through an induced inflammatory response (such as Propel) is contraindicated.12
Sickle-Cell Anemia
Orthodontic treatment is not contraindicated, but oral hygiene must be excellent and the patient should be free of any complications.• Ortho planning must be adjusted to restore the regional microcirculation by increasing the rest intervals
between adjustments (or having patients wear aligners longer than 2 weeks per aligner).• The treatment plan should reduce the movements of the teeth and the forces applied to them
(this can be requested through the Invisalign ClinCheck). Appliances (such as extra oral headgear) that apply intense orthodontic or orthopedic forces require more careful management.
• Extractions are contraindicated. If extractions are absolutely necessary, they are best carried out in a hospital by an oral maxillofacial surgeon under complete medical care.
• General anesthetics are also contraindicated and, therefore, orthognathic surgery is not recommended.3,4,5
Epilepsy/Seizures
• Removable appliances should be utilized with caution, as they can get dislodged during a seizure. • Clear aligners should be relieved around the gingival margins, and bonded retainers should be avoided,
because of the risk of drug-induced gingival hyperplasia that might be exacerbated if the aligners impinge upon, or if the bonded retainers are too close to, the gingiva.
Diabetes
Well-controlled diabetes mellitus is not a contraindication for orthodontic treatment. • The patient should be made aware of the consequences of poor oral hygiene and the increased risk of
periodontal disease.• Diabetic-related microangiopathy can affect the peripheral vascular supply, resulting in unexplained
toothache, tenderness to percussion, and even loss of vitality.• Light physiological forces should be used in all patients to avoid overloading the teeth.3,4,5
Asthma
Patients with a history of asthma seem to be at a high risk for developing excessive root resorption during orthodontic treatment.4• Therefore, low forces must be used for these patients. • Avoid supine positioning, if possible.
Allergies • If using metal brackets, use nickel-free brackets, or, preferably, Clear Aligner Therapy.4• Be aware of possible latex allergy. Invisalign aligners do not contain latex.**
Chemotherapy/Radiation Therapy
Ortho treatment should be discontinued because treatment can exacerbate thrombocytopenia and agranulocytosis.• Discontinue orthodontic treatment until one year after the patient has completed treatment and is
disease-free.• Note that roots may have been damaged during medical treatment, and orthodontic forces can damage
root structures. Care should be taken so that orthodontic forces and mechanics minimize the risk of root resorption.
• Clear Aligner Therapy may be the treatment of choice for those patients.• Discuss the pros and cons of orthodontic treatment with the patient and the patient’s physicians.3,13
Xerostomia
Dry mouth can be a problem during orthodontic treatment for two reasons: Dry tissues are more prone to irritation and ulceration, and patients with dry mouth are more prone to decay. • Therefore, it is probably best to utilize Clear Aligner Treatment rather than traditional orthodontics with its sharp
brackets and wires.• In addition, the use of fluoride supplementation along with moisturizing gels is advisable.• Without the lubricating effects of saliva, it may be much more difficult for patients to tolerate wearing
aligners. It may be advisable to test the patient’s ability to tolerate clear aligners by having the patient wear an office-fabricated, simple, vacuum-formed clear plastic aligner prior to initiating Clear Aligner Therapy.
Smoking• Smoking will cause clear aligners and retainers to stain and discolor.• Smoking has a negative effect on periodontal health, and can thus delay proper tooth movement
