June, 2006
Treatment of a Mild Crowding Patient with OrthoClear Aligners
Ross J. Miller DDS MS, Craig H. Crawford DDS and Dr. 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 Kesling [1] 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 McNamara [2] and others, [3,4] 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. Sheridan [5] 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 Figure 1. Her medical history was non-remarkable and she had her wisdom teeth taken out many years ago Figure 2. 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. Figure 3.
Figure 1. A 26 year 9 month old female patient presented with the chief complaint of lower incisor crowding secondary to previous orthodontics.
Figure 2. Her medical history was non-remarkable and she had her wisdom teeth taken out many years ago.
Figure 3. Her cephalometric radiograph shows a well-balanced skeletal structure.
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.
Figure 4. OrthoClear aligners are practically invisible while in the mouth.
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, Figure 5. approximately 12 weeks. To do the IPR we utilized strips from Brasseler Figure 6. 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. Figure 7.
Figure 5. Her mid treatment photos shows some correction occurring by the end of the wear of fourth aligner.
Figure 6. To do the IPR we utilized strips from Brasseler.
Figure 7. 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.
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. Figure 8. and 9. show x-rays of the finished case.
Figure 8. X-rays of the finished case.
Figure 9. X-rays of the finished case.
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 Figure 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 Figure 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 Figure 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.
Figure 10. Home page.
Figure 11. Case Detail page for that individual patient.
Figure 12. Patient’s 3-D treatment plan.
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” Figure 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.
Figure 13. Buttons Window Form.
In OrthoView™ there is also an Interproximal Reduction form Figure 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.
Figure 14. Interproximal Reduction form.
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 Figure 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.
Figure 15. Clinician can see the start and the theoretical goals of treatment.
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 Figure 16. without lines and ridges which stereolithography Figure 17. cannot duplicate.
Figure 16. A direct construction from an impression also allows a smoother surface.
Figure 17. A direct construction from an impression also allows a smoother surface without lines and ridges which stereolithography.
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 | 800-883-8733
OrthoClear, Inc. | 580 California St, Suite 1725 San Francisco, CA 94104 | 800-808-7173
Brasseler USA | One Brasseler Boulevard Savannah, Georgia 31419 | 800-841-4522
Contributed by:
Ross J. Miller DDS MS
Craig H. Crawford DDS
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
