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Treatment Planning Case Study 2016

Class II Malocclusion with Deep Bite and Severe Crowding Treated with Invisalign Clear TPS ClinCheck Optimization

Dr. Ann E. Haggard, DDS, Webster, TXDr. Adriana Garro-Mena, DMD, MS Orthodontics Clinical Director, Clear TPS

authorized support for Invisalign providers

Case Summary

Invisalign is an excellent option for both adult andnon-adult patients as it provides predictable andstable clinical results. As with other types oforthodontic treatment, careful diagnosis andthorough treatment planning is important toachieve the most ideal clinical outcome. It isessential that the ClinCheck treatment plan isevaluated and modified very carefully whenconsidering tooth movements and the intra/extraoral tissues to optimize the staging sequence andthe amount of movement planned to achieve thebest, most stable results. This case report presentsan adult patient with Class II malocclusion withdeep bite and severe crowding treated withInvisalign Full where Clear TPS optimized theClinCheck treatment plan representing 10%reduction in total treatment time.

Diagnosis & Treatment PlanningA 47-year-old female patient with a chief concern of a “darkfront tooth” (UL1) and misaligned teeth. Clinically, thepatient presented a Class II malocclusion with significantlower anterior crowding, protrusive upper incisors, excessiveCurve of Spee, overjet and overbite. At the intraoralexamination we found a dark upper left central incisor with ahistory of previous endodontics and apicectomy treatment(Fig1). Periodontally, the patient had thin biotype andgingival recession of LL1.

Radiographic evaluation showed a Class I skeletal patternwith a lower-than-average mandibular plane angle and upperand lower incisor inclinations within normal limits. Thepanoramic radiograph showed root resorption at the apex ofUL1, normal dental development with absence of thirdmolars (Fig 2). The patient had good soft tissue support, nosignificant facial asymmetries, an obtuse nasal labial angle,asymptomatic TMJ and no parafunctional habits.

Treatment goals included resolving crowding of the maxillaryand mandibular arches, correcting the protrusion of theupper incisors, achieving an optimal overjet and overbiterelationship and levelling the Curve of Spee. The patient wasinformed that orthodontic movement of UL1 could result infurther root resorption and potential tooth loss and thepatient decided to avoid extraction until the end oforthodontic treatment.

Fig 1

Fig 2

ClinCheck Treatment PlanThe Invisalign treatment was plan set up initially withexpansion, interproximal reduction (IPR) and noextractions. The first ClinCheck treatment plan had 29upper and lower stages and called for generalizedexpansion of 2-3mm, significant proclination of thelower anteriors and IPR (Fig 3a, 3b and 3c). This initialClinCheck treatment plan was referred to Clear TPS foroptimization of the ClinCheck.

Clear TPS evaluated the case and provided a newoptimized ClinCheck treatment plan. During the ClearTPS optimized treatment planning process it wasdiscovered that the proclination planned for the lowerincisors was outside the biological limitations. Also, thethin biotype of the gingival tissue as well as the gingivalrecession of tooth LL1 needed an optimized approach toachieve a more predictable and stable outcome thatwould take into consideration the long term health ofthe periodontal tissue.

Fig 3a

Fig 2

Fig 3b

Fig 3c

ClearTPS ClinCheck OptimizationOne of the biggest advantages of Invisalign as a treatmentmodality is the ability to use ClinCheck treatment planningsoftware as tool; in this case it allowed the Clear TPS ClinicalExperts to explore different expansion and IPR combinationsbefore making a final decision on the need for extractions. This isparticularly important for treating doctors and patients whomight be considering an extraction option as extractions areoften difficult for patients to accept.

The optimized ClinCheck treatment plan developed by Clear TPSafter only one week of modifications; this included extraction ofLL1 to solve the lower crowding and avoid unhealthy proclinationand gingival recession, decreased the overall expansion for bettergeneralized periodontal health, intrusion of lower anteriors tolevel the Curve of Spee and corrected the deep bite whilemaximizing posterior IPR to optimize the overjet and improve thecanine anterior-posterior relationship (Fig 4a, 4b and 4c).Attachments for the space closure at the extraction site werealso requested to aid with root parallelism. The approvedoptimized ClinCheck treatment plan had 26 upper and lowerstages. This represents a 10% reduction in total treatment time(3 aligners or 6 weeks of treatment time) which has implicationsof increased profitability and improved patient experience.

During the course of treatment, tooth UL1 was compromised andlost resulting in a modified treatment goal and plan forplacement of a single implant for UL1. Additional aligners wererequested to finish the anterior overjet and overbite relationshipas a total of 11 upper and lower additional aligners were neededto finish the case.

Fig 4a

Fig 4b

Fig 4c

ResultsOne of the biggest advantages of Invisalign as a treatmentmodality is the ability to use ClinCheck treatment planningsoftware as tool; in this case it allowed the Clear TPS ClinicalExperts to explore different expansion and IPR combinationsbefore making a final decision on the need for extractions.This is particularly important for treating doctors and patientswho might be considering an extraction option as extractionsare often difficult for patients to accept.

The optimized ClinCheck treatment plan developed by ClearTPS after only one week of modifications; this includedextraction of LL1 to solve the lower crowding and avoidunhealthy proclination and gingival recession, decreased theoverall expansion for better generalized periodontal health,intrusion of lower anteriors to level the Curve of Spee andcorrected the deep bite while maximizing posterior IPR tooptimize the overjet and improve the canine anterior-posterior relationship (Fig 4a, 4b and 4c). Attachments for thespace closure at the extraction site were also requested to aidwith root parallelism. The approved optimized ClinChecktreatment plan had 26 upper and lower stages. Thisrepresents a 10% reduction in total treatment time (3 alignersor 6 weeks of treatment time) which has implications ofincreased profitability and improved patient experience.

During the course of treatment, tooth UL1 was compromisedand lost resulting in a modified treatment goal and plan forplacement of a single implant for UL1. Additional alignerswere requested to finish the anterior overjet and overbiterelationship as a total of 11 upper and lower additionalaligners were needed to finish the case.

Retention was accomplished with a fixed lingual bondedretainer for the maxillary centrals in addition to Viveraretainers on both arches.

Fig 5

Fig 6

Discussion

As the clear aligner market and patient demandcontinues to increase, the variety and complexity ofmalocclusions undergoing Invisalign treatment alsocontinues to evolve. Invisalign has invested a significantamount of resources to provide doctors with thenecessary tools to achieve more predictable and stableresults however, the treatment planning decisions ofeach treating doctor are essential for successful resultsand optimal patient-doctor experience.

Clear TPS allows doctors to better identify Invisaligncases to treat and seamlessly assists with the treatmentplanning process through Clear TPS ClinCheckoptimization to improve clinical results and to enhancedoctor education, reduce ClinCheck modifications,shorten treatment time (in some cases) and increaseInvisalign opportunities which ultimately grows theprofitability of Invisalign in the practice. This case reportis an excellent example of the many benefits that bothdoctor and patient experience with Clear TPS.

ClearTPS ClinCheck Statistics

1 Kumar, SmileDesign, UK, 2012-20142 Clear Treatment Planning Solutions; 70 Single Doctor Invisalign Practices in Texas Market 2012-2013 utilizing Primarily Treatment Planning Services

Clear TPS data shows up to a

60%reduction in Case

Refinements 1

10-20% reduction of

treatment timewith Clear TPS

OptimizedClinCheck set up

Among Clear TPS users, up to an

85% increase in

Invisalign case submissions 2

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