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Treatment of complex interdisciplinary cases using a hybrid aligner approach
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Background
Align technology has developed greatly over past few years. Patients tended to prefer clear aligners over conventional brackets because of the superior comfort and esthetics, while the effectiveness of clear aligners was still controversial. The aim of this systematic review was to verify whether the treatment effectiveness of clear aligners was similar to the conventional fixed appliances.
Methods
A comprehensive search of the Pubmed, Web of Science, Embase, Scopus, and Cochrane Central Register of Controlled Clinical Trials Register databases for studies published through to August 20, 2018 was conducted. Comparative clinical studies assessing the effectiveness of clear aligners compared with braces were included.
Results
Eight papers were included in this study. Two of the included papers were randomized controlled trials and six were cohort studies. Clear aligners might not be as effective as braces in producing adequate occlusal contacts, controlling teeth torque, increasing transverse width and retention. While no statistically significant difference was found between two groups in Objective Grading System score (WMD = 8.38, 95% CI [− 0.17, 16.93]; P = 0.05). On the other hand, patients treated with clear aligners had a statistically significant shorter treatment duration than with braces (WMD = − 6.31, 95% CI [− 8.37, − 4.24]; P < 0.001).
Conclusion
Both clear aligners and braces were effective in treating malocclusion. Clear aligners had advantage in segmented movement of teeth and shortened treatment duration, but were not as effective as braces in producing adequate occlusal contacts, controlling teeth torque, and retention.
Background:
Aim was to systematically search the literature and assess the available evidence regarding the clinical effectiveness of the Invisalign® system.
Methods:
Electronic database searches of published and unpublished literature were performed. The reference lists of all eligible articles were examined for additional studies. Reporting of this review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Results:
Three RCTs, 8 prospective, and 11 retrospective studies were included. In general, the level of evidence was moderate and the risk of bias ranged from low to high, given the low risk of bias in included RCTs and the moderate (n = 13) or high (n = 6) risk of the other studies. The lack of standardized protocols and the high amount of clinical and methodological heterogeneity across the studies precluded a valid interpretation of the actual results through pooled estimates. However, there was substantial consistency among studies that the Invisalign® system is a viable alternative to conventional orthodontic therapy in the correction of mild to moderate malocclusions in non-growing patients that do not require extraction. Moreover, Invisalign® aligners can predictably level, tip, and derotate teeth (except for cuspids and premolars). On the other hand, limited efficacy was identified in arch expansion through bodily tooth movement, extraction space closure, corrections of occlusal contacts, and larger antero-posterior and vertical discrepancies.
Conclusions:
Although this review included a considerable number of studies, no clear clinical recommendations can be made, based on solid scientific evidence, apart from non-extraction treatment of mild to moderate malocclusions in non-growing patients. Results should be interpreted with caution due to the high heterogeneity.
Introduction:
The purpose of this retrospective case-control study was to compare the treatment effectiveness and efficiency of the Invisalign system with conventional fixed appliances in treating orthodontic patients with mild to moderate malocclusion in a graduate orthodontic clinic.
Methods:
Using the peer assessment rating (PAR) index, we evaluated pretreatment and posttreatment records of 48 Invisalign patients and 48 fixed appliances patients. The 2 groups of patients were controlled for general characteristics and initial severity of malocclusion. We analyzed treatment outcome, duration, and improvement between the Invisalign and fixed appliances groups.
Results:
The average pretreatment PAR scores (United Kingdom weighting) were 20.81 for Invisalign and 22.79 for fixed appliances (P = 1.0000). Posttreatment weighted PAR scores between Invisalign and fixed appliances were not statistically different (P = 0.7420). On average, the Invisalign patients finished 5.7 months faster than did those with fixed appliances (P = 0.0040). The weighted PAR score reduction with treatment was not statistically different between the Invisalign and fixed appliances groups (P = 0.4573). All patients in both groups had more than a 30% reduction in the PAR scores. Logistic regression analysis indicated that the odds of achieving "great improvement" in the Invisalign group were 0.329 times the odds of achieving "great improvement" in the fixed appliances group after controlling for age (P = 0.0150).
Conclusions:
Our data showed that both Invisalign and fixed appliances were able to improve the malocclusion. Invisalign patients finished treatment faster than did those with fixed appliances. However, it appears that Invisalign may not be as effective as fixed appliances in achieving "great improvement" in a malocclusion. This study might help clinicians to determine appropriate patients for Invisalign treatment.
Objective
To assess the accuracy of anterior tooth movement using clear aligners in integrated three-dimensional digital models.
Methods
Cone-beam computed tomography was performed before and after treatment with clear aligners in 32 patients. Plaster casts were laser-scanned for virtual setup and aligner fabrication. Differences in predicted and achieved root and crown positions of anterior teeth were compared on superimposed maxillofacial digital images and virtual models and analyzed by Student's t-test.
Results
The mean discrepancies in maxillary and mandibular crown positions were 0.376 ± 0.041 mm and 0.398 ± 0.037 mm, respectively. Maxillary and mandibular root positions differed by 2.062 ± 0.128 mm and 1.941 ± 0.154 mm, respectively.
Conclusions
Crowns but not roots of anterior teeth can be moved to designated positions using clear aligners, because these appliances cause tooth movement by tilting motion.
Objective:
To assess the scientific evidence related to the efficacy of clear aligner treatment (CAT) in controlling orthodontic tooth movement.
Materials and methods:
PubMed, PMC, NLM, Embase, Cochrane Central Register of Controlled Clinical Trials, Web of Knowledge, Scopus, Google Scholar, and LILACs were searched from January 2000 to June 2014 to identify all peer-reviewed articles potentially relevant to the review. Methodological shortcomings were highlighted and the quality of the studies was ranked using the Cochrane Tool for Risk of Bias Assessment.
Results:
Eleven relevant articles were selected (two Randomized Clinical Trials (RCT), five prospective non-randomized, four retrospective non-randomized), and the risk of bias was moderate for six studies and unclear for the others. The amount of mean intrusion reported was 0.72 mm. Extrusion was the most difficult movement to control (30% of accuracy), followed by rotation. Upper molar distalization revealed the highest predictability (88%) when a bodily movement of at least 1.5 mm was prescribed. A decrease of the Little's Index (mandibular arch: 5 mm; maxillary arch: 4 mm) was observed in aligning arches.
Conclusions:
CAT aligns and levels the arches; it is effective in controlling anterior intrusion but not anterior extrusion; it is effective in controlling posterior buccolingual inclination but not anterior buccolingual inclination; it is effective in controlling upper molar bodily movements of about 1.5 mm; and it is not effective in controlling rotation of rounded teeth in particular. However, the results of this review should be interpreted with caution because of the number, quality, and heterogeneity of the studies.
To review all the literature investigating the implications of increasing the vertical dimension of occlusion (VDO).
A comprehensive electronic search was conducted through PubMed with the aid of Boolean operators to combine the following key words: "occlusal vertical dimension," "increasing vertical dimension," "bite raising," "occlusal space," "resting vertical dimension," "rest position," "altered vertical dimension," "mandibular posture," "temporomandibular joint," and "masticatory muscles." The search was limited to peer-reviewed articles written in English and published through August 2011. Further, the literature search was endorsed by manual searching through peer-reviewed journals and reference lists of the selected articles.
A total of 902 studies were initially retrieved, but only 9 met the specified inclusion criteria for the review. From the selected studies, four variables were identified to be relevant to the topic of VDO increase: magnitude of VDO increase, method of increasing VDO, occlusion scheme, and the adaptation period.
Considering the limitations of this review, it could be concluded that whenever indicated, permanent increase of the VDO is a safe and predictable procedure. Intervention with a fixed restoration is more predictable and results in a higher adaptation level. Negative signs and symptoms were identified, but they were self-limiting. Due to the lack of a well-designed study, further controlled and randomized studies are needed to confirm the outcome of this review.
The purpose of this article is to discuss the clinical considerations related to increasing the occlusal vertical dimension (OVD) when restoring a patient's dentition. Thorough extraoral and intraoral evaluations are mandatory to assess the suitability of increasing OVD. In the literature, multiple techniques have been proposed to quantify OVD loss. However, the techniques lack consistency and reliability, which in turn affects the decision of whether to increase the OVD. Therefore, increasing OVD should be determined on the basis of the dental restorative needs and aesthetic demands. In general, a minimal increase in OVD should be applied, though a 5 mm maximum increase in OVD can be justified to provide adequate occlusal space for the restorative material and to improve anterior teeth aesthetics. The literature reflects the safety of increasing the OVD permanently, and although signs and symptoms may develop, these are usually of an interim nature. Whenever indicated, the increase in OVD should be achieved with fixed restorations rather than a removable appliance, due to the predictable patient adaptation. The exception to this is for patients with TMD, where increasing the OVD should still be achieved using removable appliances to control TMD-associated symptoms before considering any form of irreversible procedure.
To investigate the effect of increasing the vertical dimension of occlusion on facial aesthetics.
General practice.
Questionnaires were sent to 96 patients who had been treated in the practice during the period of July 1998 to December 2000, resulting in an overall 72% response rate. All these patients had had their occlusal vertical dimension increased. Photographs of patients were taken before, during and after treatment. The questionnaire asked their opinion on the effects of the treatment on their facial features. To obtain an objective view to substantiate the opinions of the patients, a panel of five judges reviewed the before and after photographs and filled in their own questionnaires.
Of the patients who responded to the questionnaire, 79.7% said they looked younger after the treatment. The panel thought 81.2% of the patients treated whose photographs they reviewed looked younger.
Increasing the vertical dimension of occlusion can have far reaching effects on facial aesthetics, not just on the peri-oral areas but on the whole face.
Changing the occlusal vertical dimension (OVD) has been one of the most controversial issues of restorative dentistry. The modification of the OVD may be indicated whenever it is necessary to harmonize dentofacial esthetics, provide space for planned restorations, and improve occlusal relationships. The OVD should not be considered an immutable reference, but rather a dynamic dimension within a zone of physiological tolerance that can be altered as long as the dentist respects the envelope of function. However, vertical changes in the relationship between the maxilla and mandible may have some biological, biomechanical, esthetic, and three-dimensional (3D) functional implications because the initial references of maximum intercuspation and anterior tooth relationships must be reconstructed and adjusted in a new dimension of space. This article aims to present a critical review of the relevant OVD literature and provide the clinical objectives and subjective parameters necessary to guide the clinician and laboratory technician during treatment involving OVD alterations.
This article shows real visual anatomical limitation of distalization of the lower molars in nonextraction treatment. The distal roots of the lower second molars were pushed to the lingual cortical bone plate and this deterred distal movement of the teeth, and produced distal and buccal tipping of the lower second molars.
Traditional interdisciplinary treatment (IDT) for simultaneous correction of complex facial, smile, and dental problems in a so-called "shortface" adult patient can be extremely challenging. Such treatment typically has been based mainly on dental diagnosis with little or no consideration given to the proper correspondence of teeth position to the patient's jaws so as to enhance overall esthetics. Modern esthetic interdisciplinary treatment (E-IDT), however, is an overall esthetics-driven treatment planning approach based on a global diagnosis rather than primarily a dental diagnosis, while still considering the patient's health and function. This article, which features a clinical report, describes treatment of a woman with a short, square face who originally was contemplating cosmetic surgery for correction of her facial features. Instead, a nonsurgical E-IDT approach was taken to successfully and wholly resolve her multifaceted disorders. The article reviews conventional treatment options for short-face adult patients and explains modern E-IDT, which may involve a combination of orthodontic therapy, implant treatment, periodontal treatment, and prosthodontic correction.
OBJECTIVE
To update the scientific evidence related to the efficacy of clear aligner treatment (CAT) in controlling orthodontic tooth movement (OTM).
MATERIALS AND METHODS
International medical databases were searched to identify all peer-reviewed papers potentially relevant to the review. The quality of evidence was ranked using the Swedish Council on Technology Assessment in Health Care Tool criteria.
RESULTS
20 relevant articles were selected and the quality of evidence was high for 3 studies, moderate for 12 studies and low for 5 studies. Mesio-distal tooth movement revealed the highest predictability, with a molar distalization up to 2.5 mm and space closure of 7 mm performed with good control. Arch expansion is predictable up to 2 mm on molars. Improvements in Little’s and PAR Index were reported in mild to severe malocclusions.
CONCLUSIONS
The overall quality of available evidence was of moderate/high level. CAT aligns and levels the arches even in severe cases, with efficient control of incisors inclination. Arch expansion and tooth bodily movement are efficiently achievable movements with CAT.
Objectives:
The objective of this study was to perform a systematic review of the orthodontic literature with regard to efficiency, effectiveness and stability of treatment outcome with clear aligners compared with treatment with conventional brackets.
Methods:
An electronic search without time or language restrictions was undertaken in October 2014 in the following electronic databases: Google Scholar, the Cochrane Oral Health Group's Trials Register, Scopus, CENTRAL, MEDLINE via OVID, EMBASE via OVID and Web of Science. We also searched the reference lists of relevant articles. Quality assessment of the included articles was performed. Two authors were responsible for study selection, validity assessment and data extraction.
Results:
Four controlled clinical trials including a total of 252 participants satisfied the inclusion criteria. We grouped the trials into four main comparisons. One randomized controlled trial was classified as level 1B evidence, and three cohort studies were classified as level 2B evidence. Clear aligners appear to have a significant advantage with regard to chair time and treatment duration in mild-to-moderate cases based on several cross-sectional studies. No other differences in stability and occlusal characteristics after treatment were found between the two systems.
Conclusions:
Despite claims about the effectiveness of clear aligners, evidence is generally lacking. Shortened treatment duration and chair time in mild-to-moderate cases appear to be the only significant effectiveness of clear aligners over conventional systems that are supported by the current evidence.
Since the introduction of the Tooth Positioner (TP Orthodontics) in 1944, removable appliances analogous to clear aligners have been employed for mild to moderate orthodontic tooth movements. Clear aligner therapy has been a part of orthodontic practice for decades, but has, particularly since the introduction of Invisalign appliances (Align Technology) in 1998, become an increasingly common addition to the orthodontic armamentarium. An internet search reveals at least 27 different clear aligner products currently on offer for orthodontic treatment. The present paper will highlight the increasing popularity of clear aligner appliances, as well as the clinical scope and the limitations of aligner therapy in general. Further, the paper will outline the differences between the various types of clear aligner products currently available.
The aim of this study was to assess treatment outcomes of the Invisalign and compare results with braces.
One hundred and fifty-two adult orthodontic patients, referred to two Orthodontic Specialist Clinics, were randomized to receive either invisalign or brace treatment. All patients were evaluated by using methods from the American Board of Orthodontics Phase III examination. The discrepancy index was used to analyze pretreatment records to control for initial severity of malocclusion. The objective grading system was used to systematically grade posttreatment records. The Wilcoxon 2-sample tests were used to evaluate treatment outcome of Invisalign and braces.
The total mean scores of the objective grading system categories were improved after treatment in both groups. The improvements were not statistically significant in scores for alignment, marginal ridges, occlusal relations, over jet, inter-proximal contacts, and root angulation. Invisalign scores were consistently lower than braces scores for buccolingual inclination and occlusal contacts.
The overall improvement in OGS scores indicate that both Invisalign and fixed appliances were successful in treating Class I adult extraction cases in this sample.
The purpose of this review was to present a comprehensive review of the scientific evidence available in the literature regarding the effect of altering the occlusal vertical dimens-ion (OVD) on producing temporomandibular disorders. The authors conducted a PubMed search with the following search terms 'temporoman-dibular disorders', 'occlusal vertical dimension', 'stomatognatic system', 'masticatory muscles' and 'skeletal muscle'. Bibliographies of all retrieved articles were consulted for additional publications. Hand-searched publications from 1938 were included. The literature review revealed a lack of well-designed studies. Traditional beliefs have been based on case reports and anecdotal opinions rather than on well-controlled clinical trials. The available evidence is weak and seems to indicate that the stomatognathic system has the ability to adapt rapidly to moderate changes in occlusal vertical dimension (OVD). Nevertheless, it should be taken into consideration that in some patients mild transient symptoms may occur, but they are most often self-limiting and without major consequence. In conclusion, there is no indication that permanent alteration in the OVD will produce long-lasting TMD symptoms. However, additional studies are needed.
© 2015 John Wiley & Sons Ltd.
Objective:
To compare three-dimensional (3D) ClinCheck™ models with the subjects' actual 3D posttreatment models using the American Board of Orthodontics Objective Grading System (OGS).
Materials and methods:
This prospective, within-subject study included 27 consecutive cases treated with aligner therapy. The posttreatment plaster models taken immediately after treatment were scanned and converted to stereolithography (STL) files; the ClinCheck models were also converted to STL format. MeshLab software was used to measure the seven components of the OGS, including alignment, marginal ridges, buccolingual inclinations, occlusal contacts, occlusal relationships, overjet and interproximal contacts. An overall OGS deduction score was also calculated.
Results:
Compared with the posttreatment models, the ClinCheck models showed significantly (P = .016) fewer overall OGS point deductions (24 vs 15). These overall differences were due to significantly (P < .05) more deductions among the posttreatment models than the ClinCheck models for alignment (4.0 vs 1.0 deductions), buccolingual inclinations (4.0 vs 3.0 deductions), occlusal contacts (3.0 vs 2.0 deductions), and occlusal relations (4.0 vs 2.0 deductions).
Conclusion:
The ClinCheck models do not accurately reflect the patients' final occlusion, as measured by the OGS, at the end of active treatment.
Cephalograms of twenty-seven untreated adult Caucasians, selected on the basis of a clinical impression of reduced lower facial height, were studied. Various linear and angular measurements were studied and compared to the Bolton standards. The short face syndrome SFS is a clinically recognizable facial type with reduced lower facial height as the common denominator. On the basis of the FPI (facial proportion index), the RH (ramus height), the OP-PP distance (or posterior maxillary height), and the SN:MP angle, two subgroups were distinguished in the SFS group. SFS, was characterized by a long ramus, sharply reduced SN:MP angle, an FPI close to 10, and a slightly reduced posterior maxillary height. In contrast, SFS2 was characterized by a short ramus, a slightly reduced SN:MP angle, an FPI with values around or below zero, and a sharply reduced posterior maxillary height. The latter group was designated as vertical maxillary deficiency.
Careful clinical studies and cephalometric and model analyses are required in the planning for treatment of vertical maxillary deficiency. The maxilla is repositioned inferiorly to elongate the face and to achieve facial balance. Simultaneous Le Fort I osteotomy with bone grafting is a helpful adjunct in the treatment of vertical maxillary deficiency in either dentulous or edentulous patients.
The short face syndrome is basically caused by one of four deviations: vertically deficient anterior height of the mandible, retropositioned mandible with pronounced vertical overbite, retropositioning of the maxilla with overclosure of the mandible, or maxillary vertical deficiency and short middle third of the face. For each group, there is a surgical standard solution, including the sandwich osteotomy of the chin, lengthening of the mandible, advancement and eventual lowering of the maxilla, and advancement with vertical lengthening of the middle third after Le Fort II osteotomy. Treatment planning depends to a great extent on clinical evaluation and the vertical discrepancy often loses its clinical importance if the anteroposterior deviation is completely corrected.
A short lower face may accompany various types of malocclusions depending on the structural etiology. Because most cephalometric analyses focus on the anteroposterior plane of space, they are often insufficient in diagnosing a significant vertical dysplasia. This article describes a cephalometric analysis that examines not only the vertical proportions of the face, but the various anatomical features that contribute to the dysplasia. Diagnosis is further enhanced by evaluating the facial profile with the mandible postured at various amounts of opening, suggesting the degree of vertical discrepancy. Traditional orthodontic therapy corrects the associated malocclusion but is usually ineffective in changing inherent facial proportions. However, several orthopedic methods have shown the ability to increase lower facial height when used in combination with nonextraction orthodontic mechanotherapy. Adults with short faces require a combination of orthodontics and orthognathic surgery. The Class II malocclusion can usually be managed by surgically advancing the mandible with the curve of Spee maintained. In cases of vertical maxillary deficiency, the LeFort I osteotomy with inferior repositioning provides the spatial correction that is needed. Two cases are presented to illustrate the cephalometric and facial analyses used in diagnosis, as well as the common surgical procedures to manage the short face patient.
Patients whose vertical discrepancies are best corrected with both orthodontics and surgery can be placed into two distinct categories. The first category is the group of patients who have short posterior facial heights in conjunction with excessive anterior facial heights. The second category is the group of patients who have the opposite problem, i.e., excessive posterior facial heights and decreased anterior facial heights. Both of these types of malocclusions can best be treated with a combination of orthodontics and surgery. Alternative treatment for these "outer limits" patients require a thorough differential diagnosis, selection of appropriate force systems, and an understanding that nonsurgical treatment will result in compromises. Although these compromises must be accepted these patients can expect treatment results that are esthetically pleasing, highly acceptable for the teeth and supporting tissues, functional, and reasonably stable if a careful differential diagnosis is followed with treatment that uses precise space management with sequential directional force application.
Facial height has a profound effect on attractiveness. Occlusal vertical dimension (OVD) determines facial proportion at maximum intercuspation and influences facial dimension at rest. Deficient facial height visibly compromises optimal facial beauty. This article explores the dependent relationships between the OVD and facial esthetics, and discusses the role of facial analysis in determining an optimal OVD.
Traditional methods of model and cephalometric examination are often unreliable for diagnosis and treatment planning. This article presents soft tissue cephalometric analysis that measures the face, analyzes important dentoskeletal structures that determine facial appearance, and reveals the etiology of malocclusions. A technique for cephalometric treatment planning for guiding esthetic facial changes and the method of occlusal correction are also described. Vertical maxillary excess and vertical maxillary deficiency malocclusions are used to illustrate these techniques.
Cosmetic dentistry has evolved with the advent of more robust porcelain materials and ever-stronger bonding agents. This series of three articles aims to provide a practical overview of what is now possible both functionally and cosmetically from the preparation of a small number of teeth, through a whole smile, to full mouth rehabilitation. A complete diagnosis is the starting point to planning any cosmetic or functional changes. Guidance is given on the techniques used but adequate training must be considered essential before embarking upon modification in occlusal schemes or even minor adjustments in smile design. Understanding vertical dimension and how and when it can be changed has always been a challenging prospect for the general dental practitioner. This article aims to discuss the rationale behind changes in vertical dimension and demonstrate how it can be achieved in general practice assuming adequate hands-on postgraduate training has been completed.
Psycho-esthetic aspects play an important role in motivating patients to undergo combined orthodontic-surgical treatment as well as in the subjective appraisal of treatment outcome. The facial soft tissues are the crucial interlink between the underlying skeletal and dental structures and their perception by the patient and his social environment. TREATMENT OF SHORT FACE SYNDROME: In the therapy of Class II malocclusions with skeletal deep bite and short lower face (short face syndrome), the soft tissues and the psycho-esthetic treatment expectations of the patient are taken systematically and appropriately into account during treatment planning and evaluation.
The respective elements of the treatment concept are outlined and explained in this article. Based on the empirical evaluation of 15 patients treated according to this concept, the soft tissue changes in patients with short face syndrome and the changes in esthetic and psychosocial self-perception are reported.
The results demonstrate the efficiency of the treatment concept in improving facial soft tissues, especially in the vertical dimension, and the resulting psycho-esthetic benefit to the patient.