Dental Asia March/April 2022

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CLINICAL FEATURE Class II orthodontic treatment using Invisalign treatment with mandibular advancement Treatment of a moderate Class II, division 1 malocclusion and ectopic permanent canines using Invisalign aligners with precision wings and extrusion elastics. By Dr Bart Iwasiuk The patient was a 13-year-, one-monthold male. His parents had noticed that his upper teeth, the permanent canines, were not coming in correctly. A diagnosis revealed that he had permanent dentition with a straight facial profile, severe Class II relationship on the right and left dental, a 5-6mm overbite, constricted upper arch with blocked-out upper canines, mild lower anterior crowding, hypocalcified spots on the permanent upper incisors, and agenesis of all third molars. TREATMENT GOALS The treatment goals were thus to bring the permanent upper canines into the arch and align all the teeth. The bite was to be corrected to Class I molar and canine without extractions. In addition, the deep bite was to be reduced, the arches widened and the smile broaded. Furthermore, the patient was to maintain good oral hygiene during and after orthodontic treatment. The treatment plan consisted of the following steps: 1. First, create proper mesial-distal space for the upper permanent canines with Invisalign aligners and weekly aligner changes, using distalisation mechanics supported with Class II elastics. Level the lower arch during this time. 2. Connect Class II elastics to buttons CEPHALOMETRIC VALUES Measurement Value Norm StDev SNA 76.8 82 3 SNB 75.2 79 3 ANB 1.6 3 2 U1-SN 102.4 103 6 L1-MP 92.9 90 5 Interincisal angle 134.2 135 11 FH-MP (FMA) 23.1 24 3 bonded to the upper canines to help them extrude (3/16” 4.5 oz. elastics full-time). This step can wait so long as the canines continue to erupt while the teeth have settled and the occlusion has stabilised. Form lingual bite ramps into the upper clear retainer if the deep bite starts to relapse.* space is being generated. 3. Re-scan the patient and add precision wings to the aligners for mandibular advancement once the canines have erupted into the arch. 4. Detail and finish the occlusion with additional aligners as needed. 5. Retain the teeth with a bonded lingual wire on upper 2-2 and lower 3-3. Add a clear retainer to the upper arch up to 45 days later, for night-time wear, once the The following Invisalign aligner features were used: • Upper canine eruption compensation feature for structural integrity of the aligner, since the actual canines are ectopic. • Optimised attachments for various tooth movements in the set-up. • Upper lingual precision bite ramps to help level the lower arch. 44 DENTAL ASIA MARCH / APRIL <strong>2022</strong>
CLINICAL FEATURE Initial records ClinCheck software set-up and staging for the initial aligners TREATMENT SUMMARY • Number of aligners used: • Upper: 27 (without precision wings) +36 (MA) +12 additional aligners (for detailing) • Lower: 29 (without precision wings) +36 (MA) +12 additional aligners (for detailing) Aligner change interval was conducted on a weekly basis. Initial aligners • Precision button cut-outs on the lower 6s for the Class II elastics. • Conventional attachments for aligner retention. • Precision wings for mandibular advancement after the permanent canines erupt. CLINCHECK SOFTWARE SET-UP AND STAGING INITIAL ALIGNERS To prepare adequate space for the permanent upper canines with minimal upper incisor flaring, the upper posterior teeth were distalised in the set-up for the initial Invisalign aligners. The ectopic canines were not included in the set-up. Instead, eruption compensation features were used, with buttons for Class II elastics bonded to the permanent canines as they erupted. The total active aligner treatment time took 18 months. This time does not include a two-month break between each aligner series to let the teeth settle into occlusion, and four weeks to order and deliver the aligners — thus, three months total between each aligner phase. In addition, buttons for Class II/canine extrusion elastics were bonded to the permanent upper canines after the first 3 months of aligner wear. The 3/16” 4.5 oz. Class II elastics were worn full time. DENTAL ASIA MARCH / APRIL <strong>2022</strong> 45
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Dental Asia March/April 2022

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