Invisalign technique in the treatment of adults with pre-restorative concerns
© Mampieri and Giancotti; licensee Springer. 2013
Received: 11 April 2013
Accepted: 10 July 2013
Published: 20 October 2013
The Invisalign method is gaining an increasing interest as an alternative treatment option in adult patient in multidisciplinary complex cases to simplify the treatment plan. The aim of this work is to show the importance of planning a multidisciplinary approach to respond at the esthetic requests of adult patients and to treat complex cases with high predictability.
Adult patients seeking orthodontic treatment are increasingly motivated by esthetic considerations. The majority of these patients reject fixed appliances, seeking instead more esthetic treatment options, including lingual orthodontics and thermoformed appliances.
Moreover, adults have often a variety of restorative and periodontal problems that can make them more difficult to treat and sometimes can compromise the results of the treatment. In the majority of these cases, the proper treatment decision should be taken after an overall evaluation on behalf of a 'team’ of an orthodontist, an oral surgeon, a periodontist, and a restorative dentist.
Since the introduction of the Invisalign technique in 1999, only a few clinicians would probably have bet on its rapid success. In fact, the number of patients undergoing orthodontic treatment with clear aligners, both adults and growing patients, has been increasing every year since then.
Despite its growing popularity and its use even in complex cases [7, 9, 10], questions still remain concerning the proper use of this technique and its limitations. Some of the limitations and disadvantages have been outlined, due to the characteristics of the material and the thermoforming process, which in specific cases can limit or even make the use of clear aligners very difficult.
The aim of this work is to show the use of the Invisalign technique in the treatment of adult patients with restorative concerns and, moreover, the importance of planning an overall approach to match the esthetic requests of the patients and to treat complex cases with high predictability.
A 41-year-old male patient presented with a Class I dental malocclusion and a Class III skeletal pattern. He was particularly concerned about his missing first upper left maxillary molar, and he wished to program an implant replacement.
An accurate examination of the occlusion highlighted a pre-contact of 1.7 as the likely cause of the open bite. The treatment plan concerning the upper arch was the intrusion of 1.7 and the uprighting of 2.7 to gain space for the implant placement. Moreover, the alignment of the upper incisors by means of expansion of the upper arch and pro-inclination of the anterior teeth was planned as well. With regards to the lower arch, the alignment was obtained by interproximal reduction and no pro-inclination of incisors. The extrusion of 1.1, 1.2, and 2.1 was programmed to correct the anterior open bite and to level margins of the upper incisors. In the lower arch, we programmed the sole extrusion of 3.1.
Intrusion of 1.7 to reduce pre-contact
Uprighting of 2.7 to gain space for the implant placement
Expansion of the upper arch and pro-inclination of the anterior teeth
Extrusion of 1.1, 1.2, and 2.1 to correct anterior open bite and to level margins of the upper incisors
Extrusion of 3.1
The first phase of therapy consisted in 15 aligners for the upper arch and 13 for the lower one. During the refinement treatment, the aligners were seven for the upper arch and eight for the lower arch.
A 37-year-old female patient presented with a dental malocclusion and a Class III skeletal pattern. She wished to improve the esthetic look of her smile, but she did not want a fixed appliance.
The treatment objectives were to resolve the crowding of both arches by expansion of the upper arch, by pro-inclination of the upper incisors and by interproximal reduction (IPR) of the lower incisor. Due to the Class III skeletal pattern, all the mentioned procedures should not have pro-inclined anterior lower teeth.
Further goal included recovering enough space for prosthetic replacement of the missing lower left first molar. This objective would have been achieved by reciprocal movements of the uprighting of the second lower left molar and by mesial movement of the left premolars to level the lower arch. In order to enable the uprighting of the 3.7, the lower left third molar was extracted. The maintenance of 3.8 was considered; however, the uprighting of 3.7 was thought to be faster and more predictable without the third molar.
On the right side, the relationship of Class III was not corrected.
To resolve the crowding by expansion of the upper arch and by pro-inclination of the upper incisors
IPR of the lower incisor, not pro-inclined anterior lower teeth
Uprighting of 3.7 to gain space for the implant placement
Mesial movement of the left premolars to level the lower arch
To ease distal tipping and to provide better control during uprighting of 3.7, two vertical rectangular attachments were bonded on the molar’s buccal side.
The first phase of therapy consisted in 8 aligners for the upper arch and 11 for the lower one. During the refinement phase, the aligners were six for the upper arch and seven for the lower one.
The small black spaces between the anterior teeth at the end of orthodontic treatment have been accepted by the patient, considering also the slight exposure at patient smiling.
The treatment objectives in this case were as follows: primarily, to rearrange anterior upper spaces to ease the solution of the right lateral incisor’s microdontia by esthetic restorative procedures, to open the space for prosthetic replacement of the missing upper left lateral incisor, to center the upper midline with the lower one, and to distalize the left upper canine in order to gain Class I relationship. Further goals included resolving lower crowding and achieving good overjet and overbite.
To rearrange anterior upper spaces to permit the esthetic restorative of 1.2
To open the space for prosthetic replacement of the missing 2.2
To center the upper midline with the lower one
To distalize 2.3 to gain Class I relationship
Resolving lower crowding
Achieving good overjet and overbite
The first therapy phase consisted of 23 aligners for the upper arch and 20 for the lower one. During the refinement phase, the aligners were five for both upper and lower arches.
As a pre-restorative treatment requires high competence on behalf of different specialists, the orthodontic phase should be performed using truly reliable devices. As illustrated in the following clinical report, the Invisalign technique indeed showed good effectiveness in successfully performing complex adult treatments. All required dental movements were enacted with no relevant counter-effects thanks to high-quality biomechanical features of the aligners. Furthermore, the treatment offered several advantages in terms of maintenance of oral hygiene and comfortable management of the removable appliance. Finally, patient satisfaction was recorded as very high, because they underwent an invisible orthodontic treatment and they reached optimal esthetics and, above all, their occlusion was functionally rehabilitated. In conclusion, for all the abovementioned reasons, we support the use of the Invisalign technique in an increasing number of adult patients with restorative and/or multidisciplinary concerns or needs.
Written informed consent was obtained from the patients for the publication of this case report and accompanying images.
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