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Clinical Orthodontics

Fig. 9: The patient had an overjet of 4 mm, and an overbite of 4 mm as well. (Photo: Dr. Bentele)
Dec 23, 2014 | Orthodontics USA

ClearCorrect treatment of crowding and constricted archforms

by Dr. Mark J. Bentele, USA

A 21-year-old male presented with a chief complaint of relapse of adolescent orthodontic treatment. He expressed an interest in clear aligner therapy for alignment and improved esthetics. Past medical history was unremarkable other than he was a nasal breather. The examination showed a slightly convex profile with a long face.

Lips were competent, but the lower lip was slightly everted due to the position of the maxillary incisor (see Figs. 1-3).

TMJs and facial musculature were asymptomatic. CR-CO slide was within normal limits. Periodontal examination showed no recession and adequate attached tissue, with a PSR score of 1 with slight bleeding on probing upper right. The patient had good oral hygiene. Third molars were absent, with moderate restorative history on teeth #2, 3, 4, 5, 13, 14, 15, 30 but no active caries. Areas of enamel hypoplasia and cervical decalcification were present.

The records taken included: photographs, a panoramic radiograph, centric occlusion bite registration and PVS impressions. The maxillary arch exhibited a mixture of crowding and spacing with a net of 0 mm arch length discrepancy. The mandibular arch exhibited 2.5 mm arch length discrepancy. The maxillary midline was right 1 mm and the mandibular midline left 1 mm. The patient had a Class I right, Class I left (1 mm discrepancy) molar relationship, with a Class I right, end-on Class II left canine relationship. Transverse maxillary/mandibular archforms were narrow. The patient had an overjet of 4 mm, and an overbite of 4 mm as well (see Figs. 4-9).

A ClearCorrect Unlimited Case was prescribed for treatment. Upon case submission, an improved upper midline was requested, along with an improved lower midline, which was limited due to crowding. We requested an idealized overjet, improved overbite and improvement of the constricted arch forms. Molar relationships were to be maintained, and proclination of the mandibular incisors was requested. We requested #11 be distalized into a proper Class I relationship. In addition we requested all spaces be closed and the teeth aligned.

ClearCorrect presented a treatment set up which estimated six phases of treatment, or 24 sets of aligners. ClearCorrect ships their aligners in phases, each of which contains four sets of aligners. This makes for a flexible system and allows changes to be made mid-treatment, with no added cost to the office. At the same time the treatment setup was received, a set of starter aligners was delivered to the patient, which fit well. The starter aligners help ease the patient into treatment, before the first phase of aligners arrive. After review, the treatment setup was approved. The patient was instructed to wear each set of aligners, including their starter aligners, for three weeks and at least 22 hours a day.

Phase 1 was received from ClearCorrect, and the patient was given the first set of aligners at our office. The second set of aligners was given to the patient to be changed at home after three weeks. The patient returned to the office after six weeks to receive the third and fourth sets of aligners. During this first phase of treatment, facial translation of premolars and canines occurred.

When Phase 2 was received from ClearCorrect, engagers were placed on teeth #7, 10, 22 and 27, and 0.3 mm IPR was performed on the mesial/distal #27, using Raintree diamond discs and followed with Duraphat fluoride varnish. Henry Schein Natural Elegance Microhybrid composite was used for the engagers, as well as Natural Elegance Flowable and Natural Elegance Universal Bond.

The engager template was cut so that it only extended a tooth and a half past the engager on either side, allowing the template to fully seat while also making the template easier to remove. A stellite, a plastic filling instrument purchased from Henry Schein (Fig. 10), was used to peel the template off laterally, rather than pulling the template off vertically which could potentially dislodge the newly placed engager. After placement of the engagers was completed, the patient received his fifth set of aligners, and was also given his sixth set to take home. Primarily facial translation and rotation of incisors would occur during this phase of treatment.

The patient continued to come in every six weeks to receive new sets of aligners. During Phase 3, a contact check on tooth #27 was performed to ensure patient compliance, and to check tracking of the teeth. Alignment of teeth #22 and 23 was completed during Phase 4, which completed the patient’s total treatment. Patient compliance was excellent throughout treatment, and there were no problems tracking or fitting of subsequent trays. The patient progressed more quickly than originally treatment planned, and only needed four phases (16 sets of aligners) as opposed to six phases (24 sets of aligners). At the end of treatment, all objectives were accomplished (see Figs. 11-18).

The patient was referred back to their general dentist, Dr. Steve Carlson of Vista Grande Dental Center, for anterior esthetic restorative treatment of tooth #8. Clearfil SE Bond was used, utilizing a layered technique with shade A1, Herculite, and Ivoclar Vivadent Tetric EvoFlow.

Due to change in shape of tooth #8, an in-house Essix aligner was fabricated for the maxillary arch, and the ClearCorrect supplied retainer was inserted for the mandibular arch. The patient was instructed to wear the retainers at nighttime indefinitely. We scheduled a follow up appointment with the patient at one month, seven months and 19 months after treatment. The patient was very happy with the results, and he is now engaged to be married in the very near future. The patient’s results truly speak for themselves, while also speaking to the effectiveness of clear aligner therapy.

 

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