Treatment
of a Mild Crowding Patient with OrthoClear™
Aligners
Ross
J. Miller DDS MS, Craig H. Crawford DDS and Ravindra Nanda DMD MDS PhD
Background
The use of removable
and flexible appliances to move teeth is nothing new in orthodontics. The
idea has been around as early as 1945 when Kesling1 described his philosophies
and methods of moving teeth with vulcanized rubber appliances made of ideal
wax set-ups. Although Kesling used his appliances for small movements performed
with one appliance, he envisioned that larger and more complex movements could
be performed with sequential appliances. The technique described consisted
of conventional wax set-ups performed in the clinician’s own laboratory but
required a considerable amount of time and effort making the process less
than practical for fabricating a series of appliances.
With improved materials
and methods described by McNamara2 and others3,4, the use of removable vacuum
formed appliances to move teeth became more common in the orthodontic office.
Although some changes were made to the process of making the appliances, it
still primarily remained an in-office procedure and labor intensive, especially
for larger tooth movements. Sheridan5 has described his technique of making
minor tooth movements using retainers fabricated of Raintree
Essix™ material with tooth movement being controlled with divots and windows.
Other products have created a series of aligners from one impression,
however there is no control over individual points in treatment. With the advent of OrthoClear™,
the laboratory work is performed by the lab and allows the clinician full
control over the set-up and the fabrication of the sequential, clear and removable
appliances via the Internet. The OrthoClear™ process is an amalgamation of
the conventional dental set-up laboratory procedures and 3-D technology, taking
the best of both worlds.
Introduction
Just as the Internet
allows people to download music and videos to their computers, it is now possible
to download orthodontic treatment and other diagnostic processes over the
Web. The new digital world we find
ourselves in is very exciting, but also a little bit scary.
Some clinicians may think they are giving up some level of control
of treatment, but this feeling may be primarily due to unfamiliarity with
web based diagnosis and treatment planning.
One of the big
differences between OrthoClear™ and other computer based clear aligners is
that clinicians can make changes with the progress of treatment. The web based
interactive program allows the clinician to communicate with the laboratory
technician to make simple to complex movements of teeth. A careful treatment
plan is essential to provide a patient with the best possible occlusion and
to achieve esthetic and functional results. However, as any clinician knows
a treatment plan often needs fine-tuning and modification with the progress
of treatment. OrthoClear™ provides clinicians a unique opportunity to alter
the originally planned tooth movements based on changes noted in the mouth.
This allows the clinician similar control as one has with traditional full
bonded orthodontic treatment.
The purpose of
this article is to show orthodontic treatment of a patient with OrthoClear™,
sequence of setting up a case and discussion of advantages of the physical
models used in the manufacturing process.
Case Report
A 26 year 9 month
old female patient presented with the chief complaint of lower incisor crowding
secondary to previous orthodontics (Fig. 01).
Her medical history was non-remarkable and she had her wisdom teeth
taken out many years ago (Fig. 02). She was seeking braces, but agreed to use OrthoClear™.
She has a pleasant smile, but with lower incisor crowding.
Her cephalometric radiograph shows a well-balanced skeletal structure
(Fig. 03).
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Fig. 01
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Fig. 02
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Fig. 03
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An intraoral examination
showed minor crowding in the lower arch and some spacing in the upper.
The treatment plan is to consolidate space in the upper arch and utilize interproximal
stripping (IPR) on the lower to relieve crowding. This treatment plan was
communicated through OrthoView™ to OrthoClear™ technicians. This patient
required no treatment modifications. That is her OrthoView™ was accepted as
presented and no changes were needed during treatment. The patient had a slight
gummy smile, which was not a part of the treatment plan.
OrthoClear aligners are practically invisible (Fig 04) while in the mouth.
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Fig. 04
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This patient wore
7 aligners on the upper arch and 9 aligners on the lower arch.
Her mid treatment photos shows some correction occurring by the end
of the wear of fourth aligner (Fig 05), approximately 12 weeks.
To do the IPR we utilized strips from Brasseler (Fig 06).
This patient had minor stripping between the lower canine to canine.
No movement was performed on the lower left 2nd bicuspid, it was felt
that a small amount of rotation was not relevant to the patient’s treatment
(Fig. 07).
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Fig. 05
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Fig. 06
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Fig. 07
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One of the key
benefits to OrthoClear™ is a constant flow of aligners to the office.
The clinician must set up tasks for the staff to monitor when aligners
are arriving. This may seem a bit cumbersome, but the advantage
of having the ability to alter treatments far outweighs any extra administrative
management of aligners. It also eliminates
the need of storing aligners as well as often discarding unused one.
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Fig 8 |
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Fig 9 |
Process
Traditional records
are taken for a thorough diagnosis and a treatment plan is developed which
includes all options. The clinician in consultation with the patient chooses
a plan which best meets the patient’s needs. The benefits and limitations
of plastic vacuum formed aligners should also be discussed.
If the final goals of the treatment cannot be met with aligner therapy,
patient must be informed regarding the possibility of using traditional braces
at the end of the treatment for finishing purposes.
The treatment plan
should include a mechanics plan about how various teeth are going to be moved.
All the movements that a clinician may need such as expansion, rotation, proclination,
torques, and tipping should be carefully considered. In patients with crowding,
a treatment plan must consider the optimal method to relieve crowding, for
example expansion, extraction or IPR or any combination. A mechanics plan
for aligner therapy is as important if not more so than traditional braces.
One must remember the finished aligner received from the laboratory will only
express changes on the teeth as noted in OrthoView™ by the clinician.
The silicone impressions
and bite registration plus copies of the photos, x-rays, and printed online
treatment form are placed in a box and sent to OrthoClear™. Once OrthoClear™
receives the records; the patient’s treatment will be set-up.
The images and accessory files associated with this process are called
OrthoView™. OrthoView™ runs entirely with in the browser of the computer be
it a Macintosh or Windows machine. There
is nothing to load from a CD or to download.
The clinician uses OrthoView™ to evaluate the case and gives input
back to technicians regarding the treatment.
With OrthoView™ the clinician can visualize gingival as well as simulated
root remodeling. This can help the doctor and lab produce a
set-up with more predictable movements.
Once OrthoView™
is accepted, the clinician starts receiving two sets of aligners every six
weeks. Patients are instructed to wear each set for three weeks. Patients
are instructed to wear them for at least 20 hours each day.
Let’s look at the
current case as OrthoView™ applies to it.
First there is the home page (Fig. 10).
Figure 10-15 are simply screen shots from the computer.
There is a list of all the patients submitted for OrthoClear therapy
and/or currently in treatment. (The
names have been blocked out for patient privacy).
This page is a summary of all the patients in OrthoClear™’s system.
With a click on the patient’s name one can open the Case Detail page for that
individual patient (Fig. 11). Information
regarding the individual patient is updated as aligners are sent. A click
on the OrthoView 3-D gives that patient’s 3-D treatment plan (Fig. 12). Similarly, a click on the Diagnosis Form, allows
a view of the completed diagnosis and treatment. There are three sections
on the diagnosis form: General Information,
Existing Occlusal Information and Treatment Goals/Objectives. Specific requests are placed in the Special
Instructions area of the Treatment Goals/Objectives area.
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Fig 10 |
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Fig 11 |
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Fig 12 |
Often to move teeth
with clear aligners ‘buttons’ may be needed at strategic places on teeth to
achieve desired tooth movements. Buttons are composite bumps bonded to the
teeth using a template, these composite bumps then couple with a window cut
in the aligner. These can be requested at the time the diagnosis form is completed
by using the “Buttons Window Form” (Fig. 13) and during treatment by clicking
on “Edit Button.” This feature allows the clinician to place buttons and remove
buttons as the doctor finds necessary during the treatment. Currently five shapes of buttons can be chosen
and a simple click allows where they should be placed on teeth. If a patient
needs more than six ‘buttons’ it may be better to offer patient traditional
clear braces as a better alternative.
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Fig 13 |
In OrthoView™ there
is also an Interproximal Reduction form (Fig 14).
This shows the total amount of IPR to be done for the case or with
the easy drop down menu one can see how much IPR is needed for each batch
of aligners delivered.
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Fig 14 |
An important part
of OrthoView™ is the “OrthoView 3D” link.
By clicking on the “OrthoView 3D” link, initially two views can be
seen. One is “initial” and the second
is “Rx View”. This is where the clinician can see the start and
the theoretical goals of treatment (Fig 15). After the clinician accepts the “Rx View”, there
will be a third view listed as “Current View”. This is the window where the
clinician can modify treatment at any time.
There are also a number of preset views and navigation tools to choose
from.
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Fig 15 |
Surface Integrity
Construction of
aligners by OrthoClear™ is quite different from other types of computer generated
clear aligners. A major difference is the use of the first pour
up from the impression. Casts are made;
teeth are cut and manipulated utilizing computer oversight. Rather than being
scanned and placed into a computer where software manipulates surfaces and
movement, OrthoClear™ aligners have more control in final construction due
to personal involvement of technicians at every step. This process allows
a customized adaptation and clarity of each aligner. A direct construction
from an impression also allows a smoother surface (Fig. 16) without lines
and ridges which stereolithography (Fig. 17) cannot duplicate.
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Fig 16 |
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Fig 17 |
Summary
OrthoClear™ offers
the Orthodontist a number of changes that can be advantageous to patient treatment:
Ability to modify
treatment, not just at the beginning of treatment, but at each stage as needed
Improved surface
integrity leading to better clarity of aligners and possibly better fit
Visualize simulated
roots on computerized set-ups
OrthoView™ works
with Windows and Apple based browsers. No special software necessary, no software
updates, viewable from any computer
Orthodontists have
many tools at their disposal to treat patients.
There are constant pressures to improve existing technologies and create
new ones. These changes are what helps keep our profession
interesting, but, require us to constantly be learning and understanding new
techniques and products.
All authors have
financial interest in OrthoClear™.
REFERENCES
1. Kesling HD.
The philosophy of the tooth positioning appliance. Am J Orthod. 1945;31:297-304
2. McNamara Jr
JA, Kramer KL, Juenker JP. Invisible retainers. J Clin Orthod. 1985;19:570-578
3. Nahoum HI. The
vacuum formed dental contour appliance. N Y State Dent J. 1964;9:385-390
4. Pontiz RJ. Invisible
retainers. Am J Orthod. 1971;59:266-271
5. Sheridan JJ,
LeDoux W, McMinn R. Minor Tooth Movement with Divots and Windows.
J Clin Orthod. 1994;28:659-663
MANUFACTURERS CITED
Raintree Essix,
Inc.
4001 Division St.
Metairie, LA 70002
1-800-883-8733
OrthoClear, Inc.
580 California
St, Suite 1725
San Francisco,
CA 94104
1-800-808-7173
Brasseler USA
One Brasseler Boulevard
Savannah, Georgia
31419
1-800-841-4522
Author Contact
Information
Ross J. Miller
DDS MS
333 West El Camino
Real Suite 260
Sunnyvale, CA 94087
408 737 1105 phone
408 733 7593 fax
Craig H. Crawford
DDS
701 W. College
St.
Lake Charles, LA
70605
337 478 7590 phone
337 478 1804 fax
Dr. Ravindra Nanda
DMD MDS PhD
UConn Orthodontic
Alumni Endowed Chair
Professor and Head
Department of Craniofacial
Sciences
University of Connecticut
School of Dental Medicine
Farmington, CT
06030-1725
860-679-2349
phone
860-679-1920
fax
Nanda@nso.uchc.edu