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
