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Treatment of severe maxillary crowding using Invisalign and fixed appliances

Authors:
Adult patients with severe maxillary-arch
crowding often have additional dental prob-
lems that can make their treatment even more
challenging. In such a case, an appropriate treat-
ment plan that corrects the malocclusion while
respecting the integrity of the dentition should be
developed by a multidisciplinary team.
Despite its limitations, the I nvisalign* system
has been used to treat adult orthodontic patients
with increasingly complex malocclusions.1-7 When
severe localized crowding is treated solely with
Invisalign, however, midcourse corrections or
refinements are often required. The combination
of clear aligners and conventional fixed appli-
ances can offer significant advantages, including
a reduced risk of root damage.
Clinicians who plan to use aligners to correct
severe maxillary-arch crowding in adults face two
major challenges. First, although the root positions
must be carefully controlled during extraction
space closure, this is one of the most significant
limitations of the Invisalign technique. If mesial
tipping exceeds 10-15° during space closure, a
segmental or full fixed appliance is strongly rec-
ommended to reposition the tipped teeth after the
aligner therapy. Second, in a case of severe local-
ized crowding, the thermoformed aligners may not
properly grip all the teeth to be moved. This situ-
ation calls for a fixed appliance to be used before
Invisalign therapy. The following patient illustrates
such treatment.
Case Report
A 30-year-old female patient presented with
a Class II malocclusion and a hyperdivergent skel-
etal pattern (Fig. 1, Table 1). She was particularly
concerned about the crowding of her maxillary
front teeth, and she also wanted esthetic treatment.
Intraoral examination showed “V”-shaped dental
arches with severe crowding on the upper right
side. The maxillary right canine had erupted
ectopically, and the lateral incisor was displaced
palatally in a crossbite position. The upper midline
was shifted 3mm to the right, and the lower mid-
line 1mm to the left. Mild crowding was also
present in the lower arch, with the left lateral inci-
sor in an edge-to-edge occlusion. All third molars
were present; the lower third molars were par-
tially erupted.
The upper left first premolar had a preexist-
ing restoration, but the upper right first premolar
was healthy. Because severe crowding was ob -
served only in the upper arch and the axial position
of the lower incisors was acceptable, extraction of
the two upper first premolars was considered the
most appropriate option. A combined treatment
plan was developed involving distalization of the
© 2009 JCO, Inc.
Treatment of Severe
Maxillary Crowding Using
Invisalign and Fixed Appliances
ALDO GIANCOTTI, DDS
RAFFAELLA DI GIROLAMO, DDS
*Registered trademark of Align Technology, Inc., 881 Martin
Ave., Santa Clara, CA 95050; www.aligntech.com.
Dr. G ianc otti is an Assis tant Profe ssor and Dr. Di Girolamo i s a clinical
consultant, Department of Orthodontics, Associazione Fatebenefratelli
per la Ricerca, Fatebenefratelli Hospital, Universit y of Rome “Tor
Ver gata”, Rome, Italy. E-mail Dr. Giancotti at g iancot t@uniroma2.it.
Dr. Di GirolamoDr. Giancotti
VOLUME XLIII NUMBER 9 583
©2009 JCO, Inc. May not be distributed without permission. www.jco-online.com
584 JCO/SEPTEMBER 2009
Fig. 2 TMA** T-loops for canine retraction.
Fig. 1 30-year-old female patient
with Class II malocclusion and hy -
per divergent skeletal pattern.
VOLUME XLIII NUMBER 9 585
maxillary canines using fixed appliances, followed
by Invisalign therapy.
After extraction of the maxillary first premo-
lars, brackets were bonded bilaterally from the
maxillary canines to the first mola rs. The canines
were retracted using T-loops in segmented .017" ×
.025" TMA** wire (Fig. 2) over a period of four
months (Fig. 3).
TABLE 1
CEPHALOMETRIC DATA
Norm Pretreatment Post-Treatment
SNA 82° ± 3.5° 79° 79°
SNPog 80° ± 3.5° 74° 75°
ANPog 2° ± 2.5°
S-N/ANS-PNS 8° ± 3.0°
S-N/Go-Gn 33° ± 2.5° 39° 36°
ANS-PNS/Go-Gn 25° ± 6.0° 31° 28°
U1/ANS-PNS 110° ± 6.0° 110° 109°
L1/Go-Gn 94° ± 7.0° 84° 84°
L1/A-Pog 2.0mm ± 2.0mm 5mm 5mm
Overjet 3.5mm ± 2.5mm 3mm 2mm
Overbite 2.0mm ± 2.5mm 3mm 2mm
U1/L1 132° ± 6.0° 116° 119°
**Trademark of Ormco /“A” Compa ny, 1717 W. Collins Ave.,
Orange, CA 92867; www.ormco.com.
Fig. 3 Patient after four months of canine retraction.
586 JCO/SEPTEMBER 2009
Treatment of Severe Maxillary Crowding Using Invisalign
The ClinCheck* projection anticipated sat-
isfactory resolution of all occlusal anomalies,
correction of the overjet and overbite, and align-
ment of the upper anterior teeth (Fig. 4). Standard
.75mm elliptical attachments were bonded to the
upper right second premolar and canine to provide
reciprocal anchorage for labial movement of the
Fig. 4 Initial ClinCheck (A) and projection of treatment outcome (B).
*Registered trademark of Align Technology, Inc., 881 Martin
Ave., Santa Clara, CA 95050; www.aligntech.com.
A
B
VOLUME XLIII NUMBER 9 587
Giancotti and Di Girolamo
upper right lateral incisor. On the left side, vertical
rectangular attachments were placed on the canine,
second premolar, and first molar to promote bodi-
ly movement during space closure. Minor reprox-
imation was required in the lower arch.
Thirty-six aligners were planned for the
upper arch and 18 for the lower arch. The patient
was seen every four to six weeks (two to four
aligners) to check for aligner fit, attachment stabil-
ity, and cooperation. The initial Invisalign phase
lasted 18 months (Fig. 5).
Because the lower left lateral incisor did not
move as intended, lingual and labial grooves were
added to the next aligner with detailing pliers. This
adjustment produced the intended rotation. The
patient needed nine refinement aligners and Class
III elastics to correct the buccal intercuspation over
the ensuing five months (Fig. 6).
The patient wore each aligner for two weeks
as directed. After 23 months of Invisalign treat-
ment, she was given clear overlay retainers to wear
in both arches at night only.
At the end of treatment, the upper anterior
teeth were aligned, and the upper right lateral inci-
sor was properly positioned (Fig. 7). No adverse
effects were observed on the adjacent teeth. The
midlines were coincident and centered in the face.
The periodontium was generally healthy, with
esthetic anterior gingival margins resulting in a
pleasant smile.
Although the angulations of the maxillary
canine roots were not ideal on the final panoram-
ic x-ray, the outcome compared favorably with
similar cases treated with fixed appliances alone.
Moreover, the roots of the upper lateral incisors
maintained a “neutral” tip, as was seen prior to
treatment. No root resorption was evident on the
final panoramic and apical x-rays.
Cephalometric analysis showed that the posi-
tions of the maxillary and mandibular incisors
changed only slightly, while the interincisal angle
increased by 3° (Table 1). The vertical dimension
was controlled to a greater extent in the upper
molars than in the lower molars, although the
intermaxillary divergence was reduced. The con-
vexity of the profile and the nasolabial angle did
not change significantly.
Discussion
The potentially traumatic effects of ortho-
dontic forces should be considered when planning
treatment for adult patients. For example, apical
root resorption is often associated with extractions
Fig. 5 After 18 months of Invisalign treatment.
Fig. 6 Case refinement using Class III elastics.
588 JCO/SEPTEMBER 2009
Treatment of Severe Maxillary Crowding Using Invisalign
Fig. 7 A. Patient after 27 months of fixed-appliance
and Invisalign treatment (continued on next page) .
A
VOLUME XLIII NUMBER 9 589
Giancotti and Di Girolamo
because of the substantial apical displacements
involved in the retraction of anterior teeth.8-12
DeShields13 and others8,10 have reported a signifi-
cant correlation between maxillary incisor retrac-
tion and root resorption. To protect the dental roots
of adult patients, most clinicians attempt to mini-
mize the amount of horizontal and vertical tooth
movement and limit the duration of treatment.
Combining fixed appliances with Invisalign
treatment is a reasonable option for a significant
number of adult patients seeking orthodontic cor-
rection of severe localized crowding. This approach
promotes and maintains the integrity and health
of dental roots and periodontal tissues, increasing
the likelihood of a good long-term outcome.
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Fig. 7 (cont.) B. Superimposition of pre - and post-treatment cephalo-
metric tracings.
B
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