CLINICAL FINDINGS • Skeletal Class II with a mildly prognathic maxilla and slightly retrognathic mandible • Class II division 1 subdivision left malocclusion • Upper and lower dental crowding • Deep overbite • Excess overjet • Buccal crossbite of tooth #5 • Maxillary dental midline was to the right of the facial and mandibular midlines • 4 partially erupted third molars • Mentalis muscle strain on lip closure and lower lip eversion in centric occlusion TREATMENT GOALS Patient’s goals did not include correcting malocclusion. Once I explained the importance of correcting malocclusion, she agreed to proceed with the recommended treatment. • Create a bilateral Angle Class I occlusion • Reduce overjet • Open deep bite • Correct buccal crossbite on the right • Relieve all dental crowding TREATMENT PLAN • Extraction of third molars to allow for distalization • Sequential distalization of the upper left posterior using Class II elastics • Retroclining maxillary incisors and proclination of the lower incisors to reduce overjet • Intrusion of incisors and canine to open deep bite • Mild arch expansion, distalization, and posterior IPR to relieve crowding PATIENT’S CHIEF CONCERN Patient, a 26 year old African American female, was uncomfortable with her smile and frequently hid her teeth. She did not know the severity of her malocclusion and simply wanted her teeth to look better. Patient wanted to straighten her teeth as discretely as possible and was unwilling to wear traditional braces. FINAL INITIAL I think it is critical for aligner therapy to be successful that the treatment is first visualized without any appliances. What do I want to accomplish and how can I get the teeth to move there? Then I would design an appliance to move the teeth in as predictable manner as possible. “In my hands, distalizing the entire maxillary dentition en masse with elastics only doesn’t work… I CAN, how- ever, very predictably distalize several teeth at a time using segmental mechanics.” DR. SCHWARTZ Class II Deep Bite Correction with Invisalign CASE STUDY Dr. Andrew Schwartz, DMD TREATMENT TECHNIQUES WITH INVISALIGN
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CLINICAL FINDINGS
• SkeletalClassIIwithamildlyprognathicmaxillaandslightlyretrognathicmandible
• ClassIIdivision1subdivisionleftmalocclusion
• Upperandlowerdentalcrowding
• Deepoverbite
• Excessoverjet
• Buccalcrossbiteoftooth#5
• Maxillarydentalmidlinewastotherightofthefacialandmandibularmidlines
• 4partiallyeruptedthirdmolars
• Mentalismusclestrainonlipclosureandlowerlipeversionincentricocclusion
TREATMENT GOALS
Patient’sgoalsdidnotincludecorrectingmalocclusion.OnceIexplainedtheimportanceofcorrectingmalocclusion,sheagreedtoproceedwiththerecommendedtreatment.
• CreateabilateralAngleClassIocclusion
• Reduceoverjet
• Opendeepbite
• Correctbuccalcrossbiteontheright
• Relievealldentalcrowding
TREATMENT PLAN
• Extractionofthirdmolarstoallowfordistalization
• SequentialdistalizationoftheupperleftposteriorusingClassIIelastics
• Retrocliningmaxillaryincisorsandproclinationofthelowerincisorstoreduceoverjet
• Intrusionofincisorsandcaninetoopendeepbite
• Mildarchexpansion,distalization,andposteriorIPRtorelievecrowding
PATIENT’S CHIEF CONCERN
Patient,a26yearoldAfricanAmericanfemale,wasuncomfortablewithhersmileandfrequentlyhidherteeth.Shedidnotknowtheseverityofhermalocclusionandsimplywantedherteethtolookbetter.Patientwantedtostraightenherteethasdiscretelyaspossibleandwasunwillingtoweartraditionalbraces.
FINALINITIAL
Ithinkitiscriticalforalignertherapytobesuccessfulthatthetreatmentisfirstvisualizedwithoutanyappliances.WhatdoIwanttoaccomplishandhowcanIgettheteethtomovethere?ThenIwoulddesignanappliancetomovetheteethinaspredictablemanneraspossible.
“Inmyhands,distalizingtheentiremaxillarydentitionenmassewithelasticsonlydoesn’twork…ICAN,how-ever,verypredictablydistalizeseveralteethatatimeusingsegmentalmechanics.”
DR. SCHWARTZ
ClassIIDeepBiteCorrectionwithInvisalign CASE STUDY
Dr.AndrewSchwartz,DMD
TREATMENTTECHNIQUESWITHINVISALIGN
ICANverypredictably,usingsegmentalmechanics,distalizeseveralteethatatime.IfIweretohavetreatedthiscaseusingfixedappliances,IwouldhavethepatientworkeduptoaheavystainlesssteelmandibulararchwireandIwouldhaverunClassIImechanicstoaslidingjigonthemaxillaryarchwiretodistalizethemolars.IwouldthenhavemadeanewjigtodistalizethepremolarsandthenfinallyswitchedtheClassIIelasticstothecanineandmoveditdistallyintoallthespaceIcreated.ThisiswhatIwantedtodoanddidwithaligners.IvisualizedthetreatmentthatIwantedtoothbytoothandhadthealignersmadeaccordingly.
Everyorthodontisthasagoodideaofhowlongthisshouldtaketoo.WhenIlookedatthiscasebeforeIstarted,itwasa2yearcase.ThereisnoreasonIshouldthinkthatalignerscantreatthecasein1year.Ihaveseenthisoccasionally.ClinChecktreatmentplanwillinitiallycomebacktomewith20aligners(10months)totreatacaseIknowwilltakeatleast18months.Thereisnoshameinrevisingtheplanfrom20to40aligners.JustbecausetheClinCheckanimationshowstheteethmovingacertainway,doesn’tmeanitwillhappenthatway.Theorthodontistneedstousetheirexperiencefromtreatingfixedcasesandmeldthatintoalignertherapy.
IntheoriginalClinchecksetup,intrusionoftheanteriorteethdidn’tstartuntilmidwaythroughtreatmentwhichIdidn’tlike.IntrusionisadifficultmovementtoachievesoIrequestedthattheintrusiveforcesonanteriorteethstartwiththefirstalignerandendwiththelast.Inthiswaythemovementperalignerwassmallerandwasspreadoveramorerealistictimeline.
Thereisabsolutelynoneedforattachmentsonincisorsinthiscasesincetheforcesareintrusive,notextrusive.Thealignermaterialitselfwillacttopushtheteethapicallywithoutanyattachment.
Ihadhorizontalbeveledattachmentsplacedontheupper4’storesisttheequalandoppositeforcescreatedfromintrudingtheanteriorteeth.Onthelower4’sIhadverticalattachmentsplacedasproperrotationwasparamount.
TIPS FOR PREDICTABLE RESULTS
Ithinkitiscriticalforalignertherapytobesuccessfulthatthetreatmentisfirstvisualizedwithoutanyappliances.WhatdoIwanttoaccomplishandhowcanIgettheteethtomovethere?Inmyhands,distalizingtheentiremaxillarydentitionenmassewithelasticsonlydoesn’twork.Forenmassemovements,IfindIneedorthopedic/heavierforcessuchasaheadgearorClassIIcorrectionappliance(thinkHerbstorFORSUS)tomoveanentiredentalarchatonce.
Treatment Detail SEQUENTIAL DISTALIZATION USING
CLASS II ELASTICS
Thepatient’streatmentplanincludedachievingaClassIocclusionviasequentialdistalizationoftheupperleftposteriorteethusingfulltimeClassIIelastics(3/16",3ozforce)onherleftside.Distalizationwastobeaccomplishedin33stages(15months),comparabletowhatittakestocorrectahalfstepClassIIinafixedcase.
ParttimeClassIIelasticwearonherrightsidewastobeusedasneededinanefforttomaintainarchsymmetry.TheClassIIelasticonherleftwouldalsohelptocorrectherdentalmidlinediscrepancy.Thethirdmolarswereextractedtoallowfordistalization.
IletthepatientgetusedtowearingalignersbeforeIinitiateelastics,typicallyataligner4.Iwillbondacompositebuttontothefacialoftheuppercanineandabondablesecondmolarbrackettothelowerfirstmolartowardsthegingival.
InClinChecksetup,Iwillalsoplaceaverticalrectangularattachmentontheuppercanineplacedtowardstheincisaledgetohelpresisttherotationalforcescreatedfromtheelastic.
OPENING DEEP BITE
Heranteriordeepbitewastobeopenedviaintrusionofthemaxillaryincisorsandrightcanineaswellasintrusionofthemandibularincisors.
Progressphoto:compositebuttononuppercanineandbracketonlowerfirstmolarforattachmentofClassIIelastics.
Verticalrectangularattachmentonmaxillaryleftcaninehelpsresistrotationalforcesfromelastic.
ClassIIDeepBiteCorrectionwithInvisalignDr.AndrewSchwartz,DMD
TREATMENTTECHNIQUESWITHINVISALIGN
Treatment Outcome TheoutcomeofthecaseIthoughtwasfantastic.TreatmentgoalswereachievedandCrystalwasextremelyhappywithherresult.I’mnotevensuresheunderstoodhowfantasticherresultwas.
ShewasretainedwithupperandlowerHawleystyleretainersthatshewastowearwhilesleepingindefinitely.Forthefirst4monthsafteractivetreatmentshewastowearherlastaligneralldayaswelltoallowtheteethtostabilize.
Aswithanytreatment,theproperdiagnosisandtreatmentplanisessentialtoanexcellentoutcome.Alignertherapyhastheaddedvariableofpatientcompliance.Theimportanceofproperlymotivatingapatienttowearthealignerscannotbeoverstated.Itisworthspending15minutesofdoctortimesittingwiththepatientandgoingoverwhy100%complianceisessential.Iwillexplaincellularbiologytopeopleifthey’llsitthroughit.Justtellingpatientstowearthealignersisn’tenough.Theyneedtoknowwhytheyshouldbewearingthem22ormorehoursperday.
Theresidualrotationsofthelowercanineswereattheveryendoftreatmentwhenthepatient’scomplianceadmittedlywaned.Ittook2caserefinementstogettothepointwhereIwassatisfied.Withbettercooperationattheendoftreatmentthiscouldhavebeencompletedinonerefinement.Thepatientwashappyaftertheinitialroundoftherapybutallowedmetocompletetreatmenttomystandards.
Treatment Challenges ThebiggestchallengeIhadwiththistreatmentwasde-rotatingthelowercanines.Afterherinitial35aligners(16months),thecrossbite,deepbite,andClassIIhadbeencorrectedbutthelower3’swerestillrotated.IhadusedverticalrectangularattachmentswhichInowregret.Ishouldhaveusedverti-calbeveledattachmentsbecauseoncetherectangularonesnolongerfitinthealigners,theforcesbecomeabhorrent.IfIweretreatingthiscasetoday,IwouldhaveusedthenewOptimizedAttach-mentprotocols.
TREATMENT TIME
2Years
ALIGNERS USED
U/L=35(16months)
REFINEMENT
Toachievelowercaninerotations
Refinement1=9alignersRefinement2=5aligners
INITIAL
FINAL
CASE STUDY
Foradditionaltreatmentdetailsandrecords,seeDr.Schwartz’presentationat:www.aligntechinstitute.com/schwartz
DR. ANDREW SCHWARTZ, DMD
ANewJerseynative,Dr.AndrewSchwartzreceivedhisBachelor’sDegreefromEmoryUniversityandhisDoctoralofMedicalDentistry(DMD)degreewithhonorsfromUniversityofPennsylvania’sSchoolofDentalMedicine.Dr.Schwartzcompletedhistwo-yearspecialtyresidencyprograminOrthodonticsandDentofacialorthopedicsattheUniversityofPennsylvania.
Currently,Dr.SchwartzislivinginBethesda,MDandispracticinginWashingtonD.C.andRockville,MD.Dr.SchwartzhasbeenrecognizedasatoporthodontistbytheWashingtonianMagazineeveryyearsinceinpracticeandhasbeenanInvisalign™ElitePremierProvidersince2006.
Dr.SchwartzisboardcertifiedbytheAmericanBoardofOrthodontics,andisanactivememberoftheAmericanAssociationofOrthodontists(AAO),theMiddleAtlanticSocietyofOrthodontics(MASO),DCDentalSociety,andAlphaOmegaDentalFraternityDCChapterofwhichheiscurrentlyPresident.
Initial Final
Superimpositions (Black=pre-treatment;Red=post-treatment)
Invisalign, and ClinCheck, among others are registered trademarks of Align Technology, Inc., July 2010 M20139 Rev 1
Initial
PanoramicX-Rays
Final
CephalometricMeasurements
Measurement Units Norm Initial FinalSNA (deg) 85.0 84.7 85.9SNB (deg) 79.0 75.5 76.0ANB (deg) 6.0 9.2 9.9Y-Axis (deg) 63.4 59.8 60.8Mx1-NA (mm) 7.0 7.6 3.5Mx1-NAAngle (deg) 24.0 27.0 16.2Mx1-APo (mm) 8.0 14.4 11.1Md1-NB (mm) 11.0 13.6 14.8Md1-NBAngle (deg) 37.0 43.1 47.6PO-NB (mm) 1.0 -0.5 -0.3OcclusalPlane-SN (deg) 18.0 23.1 23.1GO-GN-SN (deg) 38.0 39.7 39.0InterincisorAngle (deg) 119.0 100.8 106.3WitsAppraisal (mm) 1.1 2.4 2.2calculatedANB (deg) 6.0 6.6 7.0FMA (deg) 31.0 26.9 27.8FMIA (deg) 49.0 45.1 39.5IMPA (deg) 100.0 107.9 112.7IncisorOverjet (mm) 2.5 7 2.2IncisorOverbite (mm) 2.5 2.7 0.8LowerLipE-Plane (mm) 5.0 4.9 3.7
AfricanAmerican
ClassIIDeepBiteCorrectionwithInvisalign CASE STUDY
Dr.AndrewSchwartz,DMD
TREATMENTTECHNIQUESWITHINVISALIGN
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