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Treatment of anterior open bite with the Invisalign system

Authors:
  • Capital Medical University and office in Cologne
Invisalign* was initially developed to correct
mild-to-moderate crowding, to close naturally
occurring spaces, and to produce dental tipping.1,2
After years of experience with the system, ortho-
dontists have reported its successful use in more
complex cases, such as those involving extractions,
open bites, and Class II malocclusions.3-7 This
article describes two anterior open-bite patients
who were successfully treated with the Invisalign
system alone.2
Case 1
A 15-year-old female presented with anterior
open bite, anterior spacing, lack of lateral canine
guidance, tongue dyskinesia, and sigmatism dur-
ing speech (Fig. 1A). Before starting orthodontic
treatment, she was advised to undergo myofunc-
tional therapy.
Vertical rectangular attachments were bond-
ed to the upper incisors, canines, and first premo-
lars and the lower canines and premolars (Fig. 1B).
Thirty upper and 20 lower aligners were used to
close the open bite, derotate the lower premolars,
and close the anterior spaces. The refinement
phase required another 10 maxillary aligners—
seven for a 1.1mm extrusion of the maxillary
incisors and three for retraction and space closure.
After 20 months of aligner treatment, the
anterior open bite had been closed, the spaces
between the central incisors had been closed in
both arches, and canine guidance had been
achieved bilaterally, with functional overjet and
overbite (Fig. 2A). The final ClinCheck projections
closely matched the post-treatment results (Fig.
2B); frontal superimpositions of the ClinCheck
pretreatment analysis and post-treatment projec-
tion indicated the amount of relative extrusion
needed for closure of the open bite (Fig. 2C).
The patient’s bite closure and other correc-
tions remained stable 12 months a fter the comple-
tion of Invisalign treatment (Fig. 3).
© 2010 JCO, Inc.
Treatment of Anterior Open Bite
with the Invisalign System
WERNER SCHUPP, DMD
JULIA HAUBRICH, DMD
IRIS NEUMANN, DMD
VOLUME XLIV NUMBER 8 501
Dr. NeumannDr. HaubrichDr. Schupp
The authors are in the private practice of or thodontics at Hauptstrasse 50, 50996 Köln, Germany. Dr. Schupp is a Visiting Professor, Department of
Orthodontics, University of Ferrara, Italy ; e-m ail: praxis@schupp- ortho.de. Drs. Schupp and H aubrich are members of Align Technolog y’s Clinical
Educatio n Council.
*Registered trademark of Align Technology, Inc., 881 Mar tin
Ave., Santa Clara, CA 95050; www.aligntech.com.
©2010 JCO, Inc. May not be distributed without permission. www.jco-online.com
Fig. 1 Case 1. A. 15-year-old female with anterior open bite, anterior spacing, and lack of lateral canine guid-
ance before treatment. B. Pretreatment ClinCheck* analysis, showing bonded vertical attachments on upper
incisors, canines, and first premolars and lower canines and premolars.
502 JCO/AUGUST 2010
Treatment of Anterior Open Bite with the Invisalign System
A
B
*Registered trademark of Align Technology, Inc., 881 Martin Ave., Santa Clara, CA 95050; www.aligntech.com.
VOLUME XLIV NUMBER 8 503
Schupp, Haubrich, and Neumann
Fig. 2 Case 1. A. Patient after 20 months of treatment with Invisalign
only. B. Initial ClinCheck projections, closely matching post-treatment
results. C. Superimposition of pretreatment ClinCheck analysis and
post-treatment projections (treatment goal in blue).
A
B
C
504 JCO/AUGUST 2010
Fig. 4 Case 2. A. 31-year-old female with Class I molar relationship, anterior open bite, and anterior crowding
before treatment. B. Pretreatment ClinCheck analysis, showing bonded attachments on upper and lower
incisors and canines.
Fig. 3 Case 1. Stability of closed anterior bite and anterior spacing 12 months after end of treatment.
A
B
Case 2
A 31-year-old female presented with anterior
open bite, a Class I molar relationship, and ante-
rior crowding in both arches (Fig. 4A). Ricketts
analysis confirmed an open bite with no skeletal
component (lower facial height = 42.6°). We
advised myofunctional therapy to correct the pat-
tern of tongue-thrust swallowing and orofacial
dyskinesia.
Bonded attachments were placed from canine
to canine in both arches for extrusion of the ante-
rior teeth (Fig. 4B). The first phase of Invisalign
treatment involved 20 upper and 14 lower aligners.
After nine sets of aligners, the open bite had
started to close (Fig. 5). After 10 months of treat-
ment, with her bite almost closed, the patient
requested removal of the attachments for her wed-
ding (Fig. 6). Two weeks later, case refinement
began with new attachments bonded to the lower
right canine and premolars for extrusion to close
the remaining lateral open bite. Nine upper and 10
lower aligners were used in the refinement phase.
After 17 months of active treatment, the
anterior open bite had been completely closed,
proper overbite and overjet had been established,
the anterior teeth had been well aligned, and
canine guidance had been achieved on both
sides, closely matching the ClinCheck projec-
tions (Fig.
7). The upper incisors and canines had
been extruded about 2.5mm and the lower incisors
and canines 2mm; the molars had been intruded
about 1mm.
The patient wore aligners for retention.
Fourteen months after the end of Invisalign treat-
ment, the results remained stable (Fig. 8).
Discussion
Dentoalveolar open bites can be caused by
speech disorders, oral habits, or mouthbreathing
VOLUME XLIV NUMBER 8 505
Schupp, Haubrich, and Neumann
Fig. 5 Case 2. Progress of bite closure after nine
sets of aligners.
Fig. 6 Case 2. After 10 months of treatment, attachments temporarily removed for esthetic reasons.
506 JCO/AUGUST 2010
Treatment of Anterior Open Bite with the Invisalign System
Fig. 7 Case 2. A. Patient after 17 months of treatment with Invisalign
only. B. Post-treatment ClinCheck projections, showing additional ver-
tical attachments bonded to lower right canine and premolars for extru-
sion in refinement phase. C. Superimposition of pretreatment ClinCheck
analysis and post-treatment projections (treatment goal in blue).
A
B
C
due to enlarged lymphatic tissues.8-10 Positioning
of the tongue during swallowing, speech, and rest
plays an important role in the development of open
bites.11 In such cases, consultation between the
orthodontist, otorhinolaryngologist, and myofunc-
tional therapist becomes necessary before and
during orthodontic treatment. As seen in both
pa tients presented here, it is important to obtain a
functional tongue position through myofunctional
therapy to ensure stability of the treatment
results.
Invisalign offers a comfortable and almost
invisible treatment option for closing anterior open
bites. Simulated rotation of the mandible in the
ClinCheck analysis can be helpful if intrusion of the
posterior segments is planned. Virtual articulation
of the arches in centric relation may also be desir-
able in patients with craniomandibular disorders.
Close monitoring during the retention phase
is required to prevent reopening of the open bite.
The retention protocol for an open bite treated with
Invisalign appliances should be identical to that in
a case treated with fixed appliances.
REFERENCES
1. Vlaskalic, V. and Boyd, R.: Or thodontic treatment of a mildly
crowded malocclusion using the I nvisalign System, Austral.
Orthod. J. 17:41-46, 2001.
2. Boyd, R.L.: Esthetic orthodontic treatment using the invis-
align applia nce for moderate to complex malocclusions, J.
Dent. Ed. 72:948-967, 2008.
3. Boyd, R.L.: Complex orthodontic treatment using a new pro-
tocol for the Invisalign appliance, J. Clin. Orthod. 41:525-547,
2007.
4. Honn, M. and Goz, G.: A premolar extraction case using the
Invisalign system, J. Orofac. Orthop. 67:385-394, 2006.
5. Womack, W.R.: Four-premola r extraction treatment with
Invisalign, J. Clin. Orthod. 40:493-500, 2006.
6. Womack, W.R. and Day, R.H.: Surgical-orthodontic treatment
using the Invisalign system, J. Clin. Orthod. 42:237-245, 2008.
7. Norris, R.A.; Brandt, D.J.; Crawford, C.H.; and Fallah, M.:
Restorative and Invisalign: A new approach, J. Esth. Restor.
Dent. 14:217-224, 2002.
8. Fujiki, T.; Inoue, M.; Miyawaki, S.; Nagasaki, T.; Tanimoto,
K.; and Takano-Yamamoto, T.: Relationship between maxillo-
facial morphology and deglutitive tongue movement in patients
with anterior open bite, Am. J. Orthod. 125:160-167, 2004.
9. Larsson, E.: The effect of dummy-sucking on the occlusion: A
review, Eur. J. Orthod. 8:127-130. 1986.
10. Larsson, E.: The effect of finger-sucking on the occlusion: A
review, Eur. J. Orthod. 9:279-282, 1987.
11. Subtelny, J.D.: Oral habits—studies in form, function, and
therapy, Angle Orthod. 43:349-383, 1973.
VOLUME XLIV NUMBER 8 507
Fig. 8 Case 2. Stability of closed anterior bite 14 months after end of Invisalign treatment.
Schupp, Haubrich, and Neumann
... Though scholarly evidence for the system is still in infancy, 3,4 published case reports have showcased extremely encouraging outcomes with complex cases. 5,6 These cases report novelties in the literature such as those involving extractions, open bites, cross bites, and class II malocclusions. The fact that patients undergoing CAT demonstrate better quality of life (QoL) scores during treatment helps the practitioner to imbibe such treatment for their patients-also to tackle challenging cases. ...
... Despite the lack of data to support these claims, several cases ranging from mild to severe AOB have been treated successfully with the mentioned benefits of CAT. 6 A relative open bite/dental open bite usually presents itself clinically by excessive incisor proclination. 16 Among dental components, Sabri 17 claimed that proclination of maxillary incisors can significantly reduce MIDR. ...
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In open bite cases, a comprehensive diagnostic differentiation is crucial in determining the best corrective therapy. In non‐surgical open bite treatment, fixed appliances, either labial or lingual, are usually employed. With the addition of extra‐radicular screws, more sophisticated orthodontic movements may now be performed without the necessity for orthognathic surgery. Clear aligner therapy, on the contrary, has grown in popularity as a treatment option for more complex cases, such as open bite malocclusions. This article discusses three cases with an anterior open bite that were treated using various mechanics as dictated by the malocclusion. Case 1 was addressed wholly using clear aligner therapy, with careful consideration of attachment geometry and mechanics. Case 2 with clear aligner therapy, attachment geometry selection, and vertical elastics; and Case 3 with clear aligner therapy, attachments, and temporary anchorage devices.
... Varios autores describen diferentes tipos de tratamiento para corregir dicho problema, como la utilización de espolones, terapia miofuncional, alineadores, ajuste oclusal, anclaje cigomático, intrusión molar con mini-implantes y arcos multiloop. 4,[7][8][9][10][11][12][13] Se reportó una sobreerupción de molares en pacientes con mordida abierta, en comparación con pacientes que presentan un overbite adecuado, una proinclinación de incisivos superiores y una retroinclinación de incisivos inferiores en pacientes de clase III. 14 Se observó también una satisfactoria corrección de la mordida abierta con intrusión de molares, pero éstos tendían a reerupcionar entre 0.5 a 1.5 mm. 15 Una opción de tratamiento es la extracción de los primeros molares superiores e inferiores para así poder disminuir la dimensión vertical y poder aumentar la altura facial anterior. 16 Se presenta el caso de una paciente de clase III esqueletal normocefálico con mordida abierta anterior, la cual se trató con extracciones de primeros premolares superiores e inferiores. ...
... Several authors describe different types of treatment to correct this problem, such as the use of spurs, myofunctional therapy, aligners, occlusal adjustment, zygomatic anchorage, molar intrusion with mini-implants and multiloop arches. 4,[7][8][9][10][11][12][13] Over eruption of molars was reported in patients with open bite compared to patients with adequate overbite, proinclination of upper incisors and retroinclination of lower incisors in class III patients. 14 Satisfactory open bite correction with molar intrusion was also observed, but 0.5 to 1.5 mm of reeruption of these teeth was likely to occur. ...
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... Orthodontic camouflage with fixed multibracket appliance may involve dental extractions [26] or incisor extrusion [26][27][28][29][30][31], and is performed in combination with additional active auxiliaries, such as elastics [27], transpalatal arch [32] and multiloop edgewise arch wire therapy [28,33], or passive temporary anchorage devices (TADs), including dental implants [34,35], miniplates [36][37][38][39] and minis crews [40][41][42][43][44][45][46]. Recently, clear aligners, such as Invisalign® (Align Technology © , Inc, Santa Clara, California, USA), have been advocated for the treatment of moderate severity of malocclusions [47,48], including anterior open bite [49][50][51][52]. One suggested side effect of this system is the development of bilateral posterior open bite, due to the molar intrusion secondary to the thickness of the aligners between the opposing occlusal surfaces. ...
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... Schupp et al [16] also published two anterior open bite cases successfully treated with Invisalign alone. Vertical rectangular bonded attachments were used to extrude the teeth. ...
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... 7,8 Recent improvements have allowed the use of Invisalign® also in more complex clinical conditions, thanks to innovative material and attachments, more accurate software, the introduction of a new force system, and the more extensive experience gained. [9][10][11][12][13][14][15] The aim of this work is to share a dedicated procedure for the treatment of impacted cuspids by combining the use of aligners with a conventional forced eruption technique. ...
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An 18-year-old woman presented with a 6-mm dentoalveolar open bite, Class II molar malocclusion, deviated midline in both arches, slight crowding, labial inclination of the maxillary incisors, and lingual inclination of the mandibular incisors. The patient was treated with clear aligners to correct the anterior open bite and reduce the lower facial height. The results showed that clear aligners can effectively correct severe anterior open bite. The treatment was completed in 22 months, and the patient was satisfied with the esthetics and function.
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Introduction This study aimed to retrospectively evaluate the dentoskeletal effects of clear aligners (Invisalign) vs miniplate-supported posterior intrusion (MSPI) and identify factors associated with posttreatment overbite in adults with anterior open bite. Methods Twenty-nine patients treated with Invisalign and 24 with MSPI combined with full-fixed orthodontic appliances were included from 5 orthodontic practices. Pretreatment and posttreatment lateral cephalometric measurements were included as outcomes. Comparisons across groups and identification of final overbite predictors were assessed with regression modeling and machine learning techniques. Results MSPI induced significantly greater maxillary molar intrusion (1.5 mm; 95% confidence interval [CI], 0.83-2.17; P <0.001), with subsequent reduction of anterior face height (ANS-Me) (−2.77 mm; 95% CI, −3.64 to −1.91; P <0.001), Mp-SN° (−1.95°; 95% CI, −2.77 to −1.12; P <0.001), and ANB° (−1.69°; 95% CI, −2.44 to −0.94; P <0.001) compared with Invisalign. MSPI resulted in a significantly larger increase in SNB° (0.94°; 95% CI, 0.23-1.65; P = 0.01) and point-Pog projection (2.45 mm; 95% CI, 1.12-3.77; P = 0.001). Compared with MSPI, Invisalign had a significantly greater increase in the distance of maxillary (1.05 mm; 95% CI, 0.38-1.72; P = 0.003) and mandibular (0.9 mm; 95% CI, 0.19-1.60; P = 0.01) incisal edges relative to their apical bases, with borderline greater lingual tipping of only the maxillary incisors (2.82°; 95% CI, −0.44 to 6.09; P = 0.09). Appliance type and initial overbite were significant final overbite predictors across all models. However, this difference was only evident in male patients (males [1.65; 95% CI, 0.99-2.32; P <0.001]; female [−0.04; 95% CI, −0.52 to 0.44; P = 0.87]). Conclusions Both appliances effectively improve overbite. MSPI applied the correction via molar intrusion and counterclockwise mandibular autorotation, whereas Invisalign via maxillary and mandibular incisor extrusion.
Chapter
The aetiology of anterior open bite (AOB) is often multifactorial with inherited facial proportions, skeletal patterns, functional adaptations and other environmental factors contributing to the problem. This chapter describes some features of the long face and the AOB. The AOB can be classified as dental or skeletal. This classification depends very much on the original aetiological site. The principle of treatment for AOB is to understand the possibilities that can occur. These principles may be approached in a number of ways: remove the aetiology, correct the dental malocclusion, and correct the skeletal malocclusion. The presence of an AOB at an early stage should cause an orthodontist to look for prolonged and intense use of the fingers or thumb. There are three broad approaches to the treatment of AOB in the late permanent dentition. These include: clear aligners, MEAW Approach, and combined orthodontic and surgical approach.
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In this report, three patients were treated with a new treatment protocol for Invisalign to demonstrate that a variety of complex malocclusions can be successfully treated using this protocol, including correction of moderate crowding, correction of moderate Class II division 1, and deep overbite. Previous studies of Invisalign showed significant limitations for more complex orthodontic treatment, although a few recent case reports have shown successfully completed moderate to difficult orthodontic malocclusions. One reason for the discrepancy is that the earlier studies were done during the first four years of the appliance development (now ten years of clinical use), when significant problems existed with accomplishing bodily movement, torquing of roots, extrusions, and rotations of premolars and canines. The new protocol included new methods for anterior/posterior corrections, showing on the computer the effect of elastics for Class II treatment simulated as a one-stage anterior/posterior movement at the end of treatment. Staging for interproximal reduction (IPR) is now automatically staged when there is better access to interproximal contacts to avoid IPR where significant overlap between teeth is present to avoid performing IPR on surfaces that may be damaged by instruments such as burs, strips, and disks when cut on a sharp angle. Staging for tooth movements is now also done to enable combination movements to occur simultaneously for each tooth with the tooth that needs to move the most (the lead tooth) determining the minimum number of stages required. All other teeth move at a slower rate than the lead tooth throughout the duration of treatment. Attachments are now placed in the middle of the crown automatically for rotation and automatically sized in proportion to the clinical crown. Use of 1 mm thick (buccal-lingual dimension) horizontal beveled rectangular attachments is standard on premolars for retention of aligners during intrusive movements, such as leveling the lower curve of Spee in deep overbite for extrusions and for control of the tooth long axis during torquing movements. Staging of tooth movements now track linear and rotational velocities of teeth separately with the number of treatment stages determined by the lead tooth based on its rotational or linear maximum velocities at no more than two degrees of rotation per stage. Simultaneous movements are done for all teeth providing visible space (approximately 0.05 mm) between teeth during movements past other teeth using expansion instead of IPR as a primary way to increase space available for correction of crowding.
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Prolonged finger-sucking causes an anterior open bite, proclination and protrusion of the maxillary incisors, a lengthening of the upper arch and an anterior displacement of the maxilla. A postnormal or unilateral postnormal molar relationship is often associated with finger-sucking. When the sucking habit terminates, some of the dental effects will correct themselves spontaneously.
Article
In the deciduous dentition continuous dummy-sucking is almost always associated with an anterior openbite and an increased prevalence of posterior crossbite. Dummy-sucking in older children is very rare. The effect of earlier dummy-sucking in the permanent dentition is not very marked. However, there is a tendency towards an anterior rotation of the mandible.
Article
An attempt was made to review, integrate and interpret research and clinical studies of deglutition as they relate to occlusion and to the treatment of malocclusion. The effect of growth and development, thumbsucking, myofunctional therapy, mechanical restraints and surgical treatment are considered as related to correction of malocclusion and to modification of orofacial muscle activity during deglutition. Although objective data remain sparse in some areas, especially in regard to the effect of myofunctional therapy upon occlusion, the bulk of evidence indicates the specific pattern of muscular activity associated with deglutition is dictated principally by form. When form is modified by orthodontic and/or surgical procedures within the anatomical and physiological limitations of the patient and within the reference of anticipated changes incident to growth and development, stable adjustments in occlusion and favorable adaptations in orofacial muscle activity may be anticipated.
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The 35-year-old male patient was treated at the University of the Pacific, San Francisco U.S.A., as part of an on-going study investigating the feasibility of the Invisalign System of tooth movement. The study called for 40 subjects, 10 with minor, 15 with moderate and 15 with severe tooth deviation. This patient fell into the "moderate" degree-of-difficulty category, due to the position of the maxillary incisors. Treatment time with the initial series of aligners was 14 months. Treatment objectives were met, with the exception of adequate anterior overbite.
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This case report describes an interdisciplinary treatment approach using the Invisalign System (Align Technology, Inc., Santa Clara, California) for orthodontics in combination with restorative dentistry. This combined approach was selected for an optimum esthetic and functional result. This case report demonstrates how a restorative case can be improved with prerestorative orthodontic alignment. The Invisalign System was used for opening the bite anteriorly, space distribution, and midline correction. The restorative dentistry procedures involved veneering to enhance the maxillary incisor length-to-width ratio and provide anterior guidance. The cosmetic alternative treatment modality to conventional fixed orthodontics allowed the clinician to accomplish the prerestorative orthodontic goals to help meet the desires of an esthetically conscientious patient.
Article
We reported previously that patients with anterior open bite had tongue tip protrusion, slower movement of the rear part of the dorsal tongue, and earlier closure of the nasopharynx during deglutition. In the present study, the relationship between this characteristic tongue movement and maxillofacial morphology in patients with anterior open bite was investigated. The subjects were 10 female patients with anterior open bites and 10 women with normal overbites as controls. Maxillofacial morphology was measured by cephalometric radiography, and tongue movement during deglutition was analyzed by cineradiography. The relationship between each value obtained by cephalometric radiography and cineradiography was evaluated by simple correlation analysis. In the patients with anterior open bite, there were significant correlations between mandibular plane angle, ramus height of the mandible, or anteroposterior dimension of the maxilla and movement of the front part of the dorsal tongue during deglutition. Furthermore, there were also significant correlations in these patients between mandibular plane angle, gonial angle, or ramus height of the mandible and the change in the contact between tongue and palate during deglutition. The controls did not have the correlations like these. Our study suggests that characteristic tongue movements during deglutition in patients with anterior open bites are closely related to their morphological features.
Article
Introduction: Invisalign therapy is an orthodontic treatment method using removable transparent polyurethane splints. Its applicability in extraction cases is limited. This case report documents the treatment with Invisalign of a patient in whom four premolars had to be extracted due to dental crowding. Findings and diagnosis: The patient's primary objective was to undergo treatment to resolve her anterior crowding as esthetically inconspicuously as possible. Diagnostic findings were: constriction of the maxillary and mandibular arch with anterior dental crowding; proclination and anteposition of the anteriors; neutroclusion with an overjet of 6 mm and an overbite of 1 mm. The radiographs showed a mesial tilt of the lower canines and premolars and a mild skeletal Class II relationship with a vertical craniofacial configuration. Treatment progress and results: Treatment was initiated by extracting the four first premolars and placing the attachments (Tetric Ceram composite). After the Invisalign aligners had been worn, the anterior segment was uprighted and retracted, the crowding resolved, and the arches well-aligned. The patient's neutroclusion was maintained, physiological anterior relations in the sagittal and vertical planes were achieved, and the lower canines and premolars were uprighted. Active treatment lasted 1 year and 8 1/2 months and involved 43 maxillary and 28 mandibular aligners. Conclusion: Particularly in cases with an extended indication for this new treatment modality, due consideration must be given to the importance of comprehensive and meticulous diagnostics and treatment planning, and a solid grasp of the biological and mechanical fundamentals.