WINTER 2015 Journal - Alignerology

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W I N TE R 2 01 5ISSN 2372-0808 (Print); ISSN 2372-0816 (Online)theJournalThe Academy for Clear Aligner TherapyAmerican Academy of Cosmetic OrthodonticsThe Bible on FixingIATROGENICPOSTERIOROPEN BITEPage 6Case ReportsClear Aligner Treatment withConservative Composite RestorationsPage 4Innovative TechniquesThe Thermoplastic Pontic AppliancePage 14From the Hygiene ChairThe Importance of a Complete MedicalHistory in Orthodontic Treatment PlanningPage 22To receive this quarterly journal, register at www.aacortho.com

theJournalAmerican Academy of Cosmetic OrthodonticsArticle is Peer ReviewedArticle offers CE Credit at www.aacortho.comFeature Article6A Clinician’s Guide to Reducingthe Occurrence of Posterior Open Bitefollowing Clear Aligner Therapyby Mark Hodge, DMDCase ReportsProduct Review424Clear Aligner Treatment withConservative Composite Restorationsby Robert Leach, DDSInnovative Techniques14The Thermoplastic Pontic Applianceby Perry E. Jones, DDS, MAGDPerspectives from the Hygiene Chair22The Outie Toolby Nadine Saubers, RN2015 Winter Buyer’s Guide26Advertising SectionViewpoint32Thank God It’s a Root Canal!by Jeffrey M. Galler, DDSThe Importance of a Complete Medical Historyin Orthodontic Treatment Planningby Joycelyn A. Dillon, RDH, MASpecial pull-out section, suitable for chair-side reference.(see centerfold)Did You Know?Renewal of your annual AACO membershipis ONLY 99.Log on to aacortho.com for new featuresand learning opportunities, and to renewyour membership.

FeatureArticleA Clinician’s Guide to Reducing the Occurrenceof Posterior Open Bite following Clear Aligner Therapyby Mark Hodge, DMDThe desired end result of every orthodontic case is an improved,balanced occlusion with all teeth touching. However, whentreating a patient’s malocclusion using Clear Aligner Therapy,clinicians frequently report seeing a resultant iatrogenicmalocclusion that they classify as “posterior open bite.”A posterior open bite, as an unintended consequence of ClearAligner Therapy, is a fairly common obstacle in achieving theend goal of a balanced occlusion. A review of the literature,blog posts, and online CE courses paints a picture of posterioropen bite being a somewhat random “sequela” of having theocclusal surfaces of teeth covered by two layers of plasticduring the course of orthodontic treatment. According to thismodel, the masticatory forces applied to dentition that has hadits vertical dimension temporarily increased by the thicknessof the clear aligners can cause an intrusion of posterior teeth,thereby creating a posterior open bite.While intrusion of posterior teeth can occur and can beconsidered the chief etiology of some posterior open bites,it would be oversimplistic to see this as the sole cause. It isbeyond the scope of this article to address every possiblereason for a patient’s having a posterior open bite at the endof Clear Aligner Therapy. However, in my opinion after anextensive review of over 5000 Invisalign ClinChecks, posterioropen bite (POB) at the end of treatment can be attributed tofour main etiologies:1. Intrusion of posterior teeth during treatment2. Failure to recognize maxillary tooth size discrepancyDr. Mark Hodge attended the MichaelCardone, Sr. School of Dentistry at OralRoberts University and received his DMDin 1985. Since graduation, he has servedon the faculty of two dental schools:Oral Roberts University and Loma LindaUniversity. Dr. Hodge is a founding partnerof Berkshire Dental Group in Tulsa, Oklahoma, and currentlyserves as a clinical director for Heartland Dental Care.Dr. Hodge’s passion for creating great smiles with optimalfunction led him naturally to cosmetic orthodontics.Since completing his training to offer Invisalign , he hasbecome one of the leading providers in the country, and nowserves as vice president of the American Academy of CosmeticOrthodontics. He is a nationally recognized speaker on topicsincluding patient communications, team engagement,and the clinical skills required for mastering the Invisaligntechnique, and is featured in multiple Invisalign-related videosand educational resources.6the Journal: winter 20153. Development of a ClinCheck with tight overjet4. Correction (uprighting) of lingually inclined upperanteriors, followed by retraction of the anteriors, in thesame ClinCheckEffective prevention and treatment of posterior open bite (POB)will vary based upon the etiology of the new malocclusion.The purpose of this article is to equip the clinician with the toolsnecessary to reduce the occurrence of POB,recognize potential etiologies of POB, andeffectively treat POB once the etiology has been diagnosed.Each of the four dominant etiologies will be discussed, to helpmake your future cases more predictable and, hopefully, reducethe occurrence of POB in your practice. The discussion of eachpotential etiology will be accompanied by tips for correctinga POB that was caused by that etiology. Each section willconclude with recommended actions that the clinician can taketo prevent the POB from developing in the first place.

Scenario 1Posterior Open Bite via Intrusion of PosteriorsAligners are flexible, and when patients clench against them,they can intrude posterior teeth by an amount equal to thethickness of two aligners. The amount of POB is the best visualtest to confirm etiology. If the POB is only about 1.0 mm to 1.5mm, then it may be the result of intrusion. If the POB is morethan 1.5 mm, you should assume that other factors are at play,and resolving the POB will require a different approach fromwhat is recommended here.Treatment to correctThe first question is: Are all other tooth movements correct,so that POB is the only thing keeping the case from beingcomplete? If so, proceed with the recommendations below.If other movements (rotations, extrusions, etc.) are still needed,polish off attachments and do a refinement. In the refinement,specify: “Close posterior open bite by extruding posteriors andresolving anterior interferences.”If POB is the only remaining movementOnce the patient has completed wear of his or her final activealigner, trim one (or both) of the aligners, distal to the last tooththat has occlusal contact. If all posterior teeth are open, trimjust distal to the canines. If only molars and second bicuspidsare open, trim distal to the first bicuspid. If POB is unilateral,trim only the aligners on the side with the POB.Trimming the aligners allows for passive eruption of theposterior teeth. Passive eruption usually takes a minimum of6 weeks before progress is visible. To gauge your progress,when you trim the aligners, also take a segmental biteregistration over the POB segments, and store it until the nextappointment. At your first post-trimming observation visit,reinsert the bite registration over the posterior teeth.If posterior teeth are extruding, then the patient will have ananterior open bite when he or she closes against the previousbite registration.Even though posterior movements may have completedearlier in treatment, do not trim the aligners until after thepatient has completed the two weeks of wear in the finalaligner. Full posterior coverage during the two weeks thateach active appliance is to be worn provides the anchoragenecessary for the remaining anterior movements to occur.Premature trimming of the aligners could reduce youranterior finish.The potential of developing POB is one reason ourrecommended treatment preferences include overcorrectionaligners on all cases. Overcorrection aligners can help youtreat POB.If there is surplus spaceConventionally, overcorrection (OC) aligners are only indicatedto be dispensed in one situation: surplus space betweenanteriors at end of treatment. OC aligners are designed to actlike a virtual “C-chain” to pull the anteriors closer together.That is all they do. If there is no space at end of treatment, don’tuse them. If the OC aligners put pressure on the anteriors andthere is no space to close, they can cause unintended intrusion.(Since OC aligners are free, we recommend requesting themon every ClinCheck, in case you finish with surplus space dueto incomplete movement or too much IPR. On the ClinChecktimeline, OC aligners are shown in a salmon (or brownish) colorstage. Active aligners are blue, and passive aligners are grey;(see below).An alternate technique using OC alignersAlthough OC aligners are designed to close surplus space, theycan also help solve POB caused by intrusion. Let’s assume thepatient has finished wear of the active aligners with no surplusspace, but anterior heavy occlusion (i.e., POB). First, trim theupper aligner to uncover the posterior teeth that aren’t inocclusion. Then, use coarse polishing strips to create spacebetween the lower anterior teeth; finally, dispense only lowerOC aligners to close the new spaces. As the OC aligners movethe lower anteriors lingually, the heavy anterior occlusion willlessen and the vertical dimension will close. The patient shouldwear the shortened upper aligner while progressing throughthe lower OC aligners.Whenever they are used, OC aligners should be dispensed oneat a time and checked every 2 weeks. Dispense the next OCaligner only if there is still interproximal space present, or ifyou wish to repeat the process by creating more interproximalspace and then using the OC aligners to close the space andfurther correct the posterior open bite.In addition, in order to further lessen the heavy anteriorocclusion, don’t be bashful about contouring the lingual ofupper incisors with a football-shaped bur and smoothingthe incisal edges of lower anteriors. I recommend evaluatingevery case for enamelplasty at the end of orthodontia.Finishing a case with minor occlusal equilibration and cosmeticrecontouring will make the case more stable and more esthetic.In addition, this enamelplasty may simplify the correction ofany POB.If the posterior teeth do not extrude as needed via passiveeruption, extrusion can be facilitated with refinement alignersor the use of bonded buttons and elastics. More information onextrusion with elastics can be found in this webinar:https://learn.invisalign.com/ce sessions/archived/20Prevention of POB via intrusionIntrusion is not inevitable yet is fairly predictable inpatients who are heavy clenchers. Intrusion is more commonin cases that extend beyond 23 aligners in duration.Posterior intrusion will be less if your clinical preferences areset to our recommended clinical preferences (see page 13),since the preferences are designed to help facilitateshorter cases.the Academy for Clear Aligner Therapy7

Feature ArticleOne preventive measure is to trim passive aligners 4 to 6 weeksafter active movement in the arch ceases. Passive aligners allowfor both arches to finish simultaneously. However, their useincreases the length of time that the posterior teeth are coveredby two layers of plastic. Once one arch enters the passive phase,consider trimming the passive aligners after the second or thirdpassive aligner. This will enable the shortened passive alignersto retain the anterior teeth yet allow for passive eruption of theposterior teeth in that arch.Patients who are clenchers often have little overjet and/ora deep bite. Bite ramps, applied to the lingual of the upperanteriors, will help to keep the intruding forces of the occlusionoff the posterior teeth. More information on use of bite rampsis available online using the following link:https://learn.invisalign.com/ce sessions/archived/559Because posterior intrusion is unpredictable, it is not alwayspossible to prevent it. However, POB caused by intrusion isrelatively easy to correct.Scenario 2Posterior Open Bite via Tooth Size DiscrepancyDental research estimates that tooth size discrepancy (TSD)occurs within 22.9%-37.9% of the population (depending uponthe study and the population sample being considered).TSD should always be considered in cases where there aredissimilar arch issues, such as spacing over crowding, or mildcrowding over heavy crowding.The most frequent TSD is undersized maxillary lateral incisors.While the golden proportion of smile design relates tothe visual display of teeth, statistical norms for the actualmeasurements of teeth indicate that an upper lateral incisorshould be (at minimum) approximately 65% of the width of thecentral incisor (Figure 1).If the presence of undersized lateral incisors goes undetectedand treatment consists of closing all space, then the envelopeof function will be constricted. This results in the case finishingwith heavy anterior occlusion and a posterior open bite.Treatment to correctA case with a constricted envelope of function is very prone torelapse. Resolving the POB entails correcting the heavy anteriorocclusion by creating a set of refinement aligners.Ideal resolution uses refinement aligners to procline the upperanteriors and create residual space distal to the lateral incisors.The laterals are then restored to proper width and morphologyvia veneers or bonding. Obviously, it may be difficult to addressthe prospect of additional treatment and expense with thepatient at this stage if it wasn’t discussed initially.If restoring the laterals is not a viable option, then therefinement will consist of creating upper anterior lingualroot torque, lower anterior IPR, and/or intrusion of thelower anteriors.8the Journal: winter 2015Figure 1: golden proportion of smile design.Prevention of POB via tooth size discrepancyThe best way to prevent POB via tooth size discrepancy is toassume every case has a TSD until you rule it out. This will allowyou to have a pre-treatment conversation with the patientabout the need to restore the laterals after the orthodonticsare complete. My experience is that about 50% of the patientsunderstand the need/benefit and elect the combinationorthodontic/restorative option. The remaining 50% choosean orthodontic-only option and accept that moderate tosignificant lower IPR will be necessary.If patient elects the combination orthodontic/restorativeoption, use the following tip when developing your ClinCheck:Once you have your ClinCheck set to accomplish all yourorthodontic goals, request 1 final modification prior toapproving the ClinCheck. Make the following request:“Please provide 1 additional stage to the upper treatmentand place virtual pontics of ideal width and morphology overteeth #7 and #10.”This will give you a “digital wax-up” of a simulated veneer,mimicking your overall treatment goals. This “digital wax-up”serves to remind patients that they committed to restorativetreatment after the orthodontics and gives them a visualpreview of the completed combination treatment. In addition,it will generate an aligner that can be used to help form yourtemporary when you prep the teeth for veneers (Figure 2).Scenario 3Posterior Open Bite via Tight OverjetClear Aligner technicians, by default, focus on aligning thelingual of upper anteriors, as a priority over aligning the facialsurfaces of the anteriors. They do this to help avoid irregular

Figure 2a: peg lateral.Figure 4: mark centric stops with articulating paper prior toInvisalign photos.Figure 2b: virtual pontic.of the lower anteriors. Frequently, the lower anteriors haveragged edges and wear facets, and the patient appreciates thecosmetic enhancement.As with the case of POB via intrusion in Scenario #1, don’t bebashful about contouring the lingual of upper incisors with afootball-shaped bur and smoothing the incisal edges of loweranteriors. Evaluate every case for enamelplasty at the end oforthodontia. Finishing a case with minor occlusal equilibrationand cosmetic recontouring will make the case more stable andmore esthetic.Prevention of POB via tight overjetExperience has shown that clinical overjet is often less thanoverjet shown on the ClinCheck. Steps to take in preventing acase from finishing with tight overjet includeFigure 3: lingual of upper centrals.or heavy anterior occlusion. However, as a result, your firstClinCheck will sometimes not meet your esthetic criteria. As youmodify the ClinCheck, recognize that almost every time youadjust the orientation of the facial of the upper incisors, youare moving the lingual of the upper anteriors toward the facialof the lower incisors, decreasing overjet. Decreased overjetincreases the potential of posterior open bite.Treatment to correctThe most expedient means of correction for POB due to lack ofoverjet is occlusal adjustment/enamelplasty. Focus on adjustingthe bulbous mounds of enamel on the lingual of upper centrals(Figure 3). Also, smooth/shorten/polish the incisal edges marking the occlusion with articulating paper when you takeyour initial Invisalign photos, and setting your treatment preferences to request 2.0 mmof overjet.Marking the occlusion with articulating paper prior to takingyour photos will allow you to send those occlusal markingsto the technician who develops your ClinCheck. With thisinformation the technician can give you a more accuratebite set, reducing the potential for a tight overjet that causesanterior interferences and POB (Figure 4).Our recommended clinical preferences include a requestto finish with 2.0 mm of overjet. While you may not wantthat much overjet clinically, requesting it in the ClinCheckreduces the potential for a tight overjet that causes anteriorinterferences and POB. Most often your case will finish with lessoverjet in the mouth than what is shown on the ClinCheck.the Academy for Clear Aligner Therapy9

Feature ArticleOn the rare occasion when you finish with more overjet thandesired, a refinement to correct surplus overjet is much easierto do than a refinement with too little overjet and POB.Scenario 4Posterior Open Bite via Correction of LinguallyInclined Upper Anteriors withAccompanying RetractionWhen treating cases and evaluating ClinChecks, it is mostvaluable to think in multiple planes of space and honor the factthat the mandible is simply suspended in space by musclesand ligaments. The ClinCheck software cannot illustrate thisdynamic and typically shows a static hinge axis. It is up to thetreating doctor to mentally incorporate the dynamics of thejoint into the ClinCheck evaluation.This is of particular importance when treating patients withsignificantly lingually inclined upper anteriors (Figure 5).Failure to take the dynamics of the joint into consideration onthese cases will often yield a case with heavy anterior occlusionand a posterior open bite that is difficult to correct.For Class II Division 2 cases like this one, I recommendaddressing the bulk of the anterior-posterior (AP) correction inrefinement, not the first ClinCheck. Here’s the explanation:The lingual inclination of the upper anteriors has often causeda posterior entrapment of the mandible. As you correct thelingual inclination of the upper anteriors, you can get a passive,postural forward repositioning of the mandible. If you first doa lot of upper IPR on your first Clincheck to reduce the overjetshown with a static hinge axis, and then the mandible relaxesand shifts forward.you’re sunk. This is why many cases finishwith anterior-only occlusion. This is particularly common if youattempt to use Invisalign Assist to treat a Class II Division 2 case.My recommendation is to treat almost all Division 2 cases in2 stages: First, do a ClinCheck with no (or very conservative)maxillary IPR; then, adjust AP issues in refinement once youcan assess the patient’s centric relation without the anteriorinterferences. Attempting to treat a case with a single ClinCheckwhen you have a known anterior occlusal interference willalways yield a frustrating time trying to finish the case. Use thefirst ClinCheck to correct the anterior interferences and free upthe mandible. Then do a refinement. It is much easier to moveprogressively and sequentially than to try to undo IPR.Treatment to correctIf you have a case in which you treated lingually inclined upperanteriors with upper IPR and then finished with heavy anteriorocclusion and a posterior open bite, there are steps you cantake to address the POB.First, look to perform any possible occlusal adjustment/enamelplasty to reduce the anterior interference. Also, look forany needed posterior restorative work that needs to be donethat might allow you to restore one arch to an increased10the Journal: winter 2015Figure 5: lingually inclined upper anteriors.vertical dimension. Next, refinement with lower IPR will mostlikely be indicated. Additionally, posterior vertical elastics maybe needed to extrude the posteriors (Figure 6). Informationon posterior extrusion with elastics is discussed in the followingwebinar: https://learn.invisalign.com/ce sessions/archived/20.Prevention of POB via correction of linguallyinclined anteriorsDo not use Invisalign Assist for Class II Division 2 cases, or caseswith upper anteriors that have heavy lingual inclination.

ConclusionFeature ArticleClear Aligner Therapy is an effective, predictable orthodontictreatment modality and can be reliably used to achieve thestated treatment goal of an improved, balanced occlusion withall teeth touching. While no clinician can achieve 100% successwith 100% of his or her cases, posterior open bite need not bethe issue that prevents clinicians from reaching their treatmentgoals. Clinicians can effect a reduction in the occurrence ofiatrogenic posterior open bite by: Accurately diagnosing maxillary tooth size discrepancy andfactoring the discrepancy into the treatment regimen; Establishing an initial ClinCheck that finishes with excessive“digital overjet” so that the clinical overjet is adequate; and Treating Class II Division 2 cases in two stages:1) Correction of lingually inclined anteriors; and2) Retracting the anteriors in a refinement seriesof aligners. nEditor’s NoteFigure 6: posterior extrusion elastics.You may wish to consider asking more experienced Invisalignproviders, or posting a blog question on the American Academyof Cosmetic Orthodontics website, when treating such cases.When treating Class II Division 2 cases, or cases with upperanteriors that have heavy lingual inclination, use the firstClinCheck to correct the anterior interferences and free up themandible. Then do a refinement. While the total number ofaligners may seem like a lot, most often this approach will yielda shorter treatment time, a happier patient, and a more stableocclusion, compared to attempting to do it all in one ClinCheckand then having to fix a POB with elastics.For further information about posterior open bites, readers maywish to refer to these past articles in the Journal of the AmericanAcademy of Cosmetic Orthodontics:1. How to Avoid the Dreaded, Iatrogenic Open Posterior Bite,by Dr. Adam Goodman, AACO Journal, Winter 2013,pages 33-35.2. How to Treat the Dreaded, Iatrogenic Open Posterior Bite,by Dr. Adam Goodman, AACO Journal, Spring 2013,pages 30-32.Like this Journal?The AACO believes strongly in its“Strength in Numbers” philosophy.Share past issues of the Journal with your colleagues,and promote the benefits of membership.Log in TODAY to see what’s new! www.aacortho.com12the Journal: winter 2015

rane wiseonearchfinishese arlyandthepatientwearsthelastalignersfora nextendedperiod,creatingahygieneissuea ooth- detofitintothesmileproperly,andthec eferencewillgiveyouaninitialClinCheckwithcaninea ist,thenyoucane ingivalthanthecentrals.Trimminga VirtualC- gnersarenicetohaveifyouaccidentallydotoomuchIPR.I fyouselectthevirtualC- ‐chain,bothyoua ndthepatientneedtoknowthatrealt rtorefinementorretainers.the Academy for Clear Aligner Therapy13

Perspectivesfrom the Hygiene ChairThe Importance of a Complete Medical History inOrthodontic Treatment Planningby Joycelyn A. Dillon, RDH, MADental hygienists play a key role in making sure that the dental office obtains a complete and comprehensive medical history beforeinitiating any treatment. An often overlooked consideration is the importance of how medical findings can affect an orthodontictreatment plan.Joycelyn Dillon is an Associate Professorand Chair of the Dental Hygiene programat New York City College of Technology.She also practices clinical dental hygiene,and is an extended member of theNew York State Board for Dentistry.Passionate about her profession,Professor Dillon teaches periodontics and clinical dentalhygiene. She lectures on a variety of topics and also providescommunity services.The goal of a treatment plan is to achieve optimal oral health,esthetics, and function for the patient. In treatment planningfor a prospective orthodontic patient, there are two primaryquestions to be addressed: What is the patient’s main concern?And, perhaps even more important, are there any medicalcontraindications or significant considerations to be mindful ofin treatment planning?The role of the dental hygienist as a co-clinician in treatmentplanning for the medically compromised orthodontic patientis extremely significant. The patient will ordinarily state his orher main concern upon first arriving, or even when calling tomake the first appointment. Nonetheless, an interview with thepatient or parent/guardian can provide the clinical team withcrucial details about the patient’s present status and the resultswhich he or she wishes to obtain, even before the tools ofradiography, photography, and intra- and extraoral examinationare brought to bear.22the Journal: winter 2015A thorough review of the medical history is, in many respects,the most significant procedure to determine whether there arecontraindications or important modifications to the treatmentof the particular case. Here again, the hygienist can begin tomake determinations regarding treatment contraindications assoon as the patient is sitting in the dental hygiene chair.Orthodontics is noninvasive, so there are not manycontraindications for treatment, yet a thorough assessmentcan yield valuable and useful information that will guide thetreatment plan and ensure the patient’s safety. This paper willpresent a partial review of some of the diseases and conditionsthat might be present in a patient seeking orthodontic care,along with recommendations regarding contraindications andtreatment modifications by the dentist and dental hygienist foreach condition.The dental hygienist must be knowledgeable regardingcommonly occurring conditions and their possible treatmentimplications. The presence of any of these conditions in thepatient’s history should prompt an interview by the hygienistto glean additional details. The hygienist should then highlightthe areas of concern, thereby alerting the dentist of the needfor special considerations in planning the treatment of the case.A preliminary discussion of findings between the hygienist andthe dentist, as well as consultation with the patient’s physician,may be warranted, depending on the seriousness ofthe condition.After consideration of the medical history, the dentalhygienist should perform an intra- and extraoral examination,documenting findings such as the class of occlusion,parafunctional habits, and soft tissue status. In addition,

the hygienist should note specific considerations that affectthe patient’s dental hygiene care and oral hygiene education.*According to the American Dental Association:The tear-out table in the center of this issue of the Journal(also available for download at aacortho.com) comprises apartial list of conditions, medical history findings, and specialconsiderations in dental hygiene and orthodontictreatment planning.groups of patients:Antibiotic prophylaxis recommendations exist for two to infective endocarditis The author thanks Dr. Perry Jones and Dr. Eli Halabi for theirinvaluable contributions in helping prepare this article.References1.Darby ML, Walsh M. Dental Hygiene: Theory and Practice. 1st ed. Philadelphia, PA:Saunders; 1995: chap 29.2.Burden DJ, Coulter WA, Johnston CD, Mullally B, Stevenson M. The prevalenceof bactaeremia and orthodontic treatment procedures. Eur J Orthod. 2004Aug;26(4):443-447.3.Burden D, Mullally B, Sandler J. Orthodontic treatment of patients with medicaldisorders. Eur J Orthod. 2001 Aug;23(4);363-372.4.Duggal S, Kapoor DN. Orthodontics and medical disorders:Clinical considerations. Orthod Cyber J. 2012 Jul. http://www.orthocjcom/2012/07/orthod

extensive review of over 5000 Invisalign ClinChecks, posterior open bite (POB) at the end of treatment can be attributed to four main etiologies: 1. Intrusion of posterior teeth during treatment . a deep bite. Bite ramps, appl

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