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Clear aligner therapy a case report

SM Dawjee B.Ch. D., B.Ch.D. Hons, M.Sc.(Odont), M.Dent. (ortho), P.G.Dip.IRE, Ph.D.
S Monehi B.Ch. D., M.Dent. (ortho).

Corresponding author:

Prof. S.M. Dawjee: Department of Orthodontics, University of Pretoria, P.O. Box 1266,
Pretoria, 0001. Email: s.dawjee@up.ac.za Tel: 0827786450.

Keywords: Aligner therapy, Invisible braces

Introduction
The aesthetic disfavour of conventional brackets has resulted in the pursuit of invisible braces.
This quest is mainly due to increased requests from patients for a more cosmetic appliance in
solving their orthodontic problems. Invisible braces are mainly requested by adults with busy
schedules, who hold high profile positions at work and are more conscious of their appearance.
The conventional orthodontic appliance is mainly positioned on the labial surfaces of teeth.
There have been many efforts to improve aesthetics of orthodontic appliances used during
orthodontic treatment. These include the use of clear brackets, lingual brackets and clear
aligners.
Different fixed orthodontic appliances have their advantages and disadvantages. Lingual
appliances offer patients an aesthetic benefit but they are not without short fall. The
disadvantages of lingual appliances include speech that is negatively affected, longer chair time,

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and a final occlusion that sometimes is not always ideal.1,2 Registrars at the University of
Pretoria

have been able to treat a patient with ClearPath aligners. The ClearPath

Orthodontic Company was established in 2007 and has a wealth of experience in the field of
Clear Aligner Therapy (CAT).3

Case presentation
A 21-yr old female patient presented at the Postgraduate Clinic at the University of Pretoria
with the main complaint of crowded anterior teeth. She was part of a stage production and had a
busy schedule. We had to plan her treatment appointments around her commitments. Consent
was obtained from the patient to use her records for the purpose of publication.

Clinical examination
Cinical examination revealed that she had a straight profile with a normal growth direction. She
had an overjet of 3mm, overbite of 4/10, and space shortage in the upper arch of 4,4 mm and 4,8
mm in the lower arch. Teeth 12, 22, 23, 31 and 41 were rotated and a Class I molar and canine
relationship was present with coincident upper and lower midlines (Figures 1-9)

Pretreatment photographs:

Figure 1 Frontal in repose

Figure 2 Frontal smiling

Figure 3 3/4 smiling

Figure 4 Profile

Figure 4 Maxillary occlusal

Figure 6 Right buccal occlusion

Figure 5 Mandibular occlusal

Figure 7 Anteriorocclusion

Figure 8 Left buccal occlusion

Cephalometric evaluation
The cephalometric evaluation revealed that she had a skeletal Class I pattern with normal
growth direction. The upper incisors were well positioned in their respective arches (Figure 10).

Figure 10 Cephalometric analysis

Treatment objectives and treatment Planning

Treatment objectives for this case include maintaining the Class I molar and canine relationship,
retaining the overjet and overbite and midlines in their appropriate current position, and
correcting the rotations. Two treatment options were presented to the patient. The first entailed a
non-extraction approach using upper and lower full fixed appliances with interproximal
reduction of selective teeth. The second treatment option also involved a non-extraction
approach but would use ClearPath aligners and interproximal reduction. For reasons of
aesthetics and comfort, the patient chose the second treatment option.

Treatment
Diagnostic records of the patient were then taken and submitted to ClearPath Orthodontic
Company. Figure 11 illustrates the type of records that are necessary for case submission. These
include:

Impressions
o

Upper Impression

Lower Impression

Intra oral

Photographs
o

Extra oral

Lateral Cephalometric and Panoramic Radiographs

Bite registration
Complete Diagnostic and Treatment form

Figure 11 Records required for ClearPath aligner case submission3

Impressions of the upper and lower arches where acquired using a proprietry light and heavy
body polyvinyl siloxane (PVS) material in two steps. The polyvinyl siloxane impression
material is preferred as it has a longer shelf life and it can withstand multiple pours without
damaging the impression details. The bite registration was taken using the PVS light body
impression material. Both the impressions and bite registration that was registered in centric
occlusion, were disinfected and packaged before shipment to the ClearPath Orthodontic

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Company. The progress and delivery date of the Clearpath aligners were tracked online. The
online virtual set up also allows for requests to amend final product.
Twenty two sets of aligners were returned and were to be used by the patient over a treatment
period of thirteen months. Each set had two aligner trays, one for the maxilla and one for the
mandible which were worn by the patient for two weeks. The patient was educated on the wear
and maintaining hygiene of the aligners, which were replaced with a new set at the end of the
two week period.

Selective interproximal reduction was done at specific stages during

treatment to create space for effective levelling and aligning.

Figures 12 to 29 illustrate treatment progress at different stages during treatment.

02/10/2013

Figure 12 Maxillary occlusal

Figure 13 Frontal

Figure 14 Mandibular occlusal

Figure 16 Frontal

Figure 17 Mandibular occlusal

13/12/2013
0

Figure 15 Maxillary occlusal

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21/02/2014

Figure 18 Maxillary occlusal

11/06/2014

Figure 21 Maxillary occlusal

occlusal

Figure 19 Frontal

Figure 9 Frontal

Figure 20 Mandibular occlusal

Figure 10 Mandibular

12/09/2014

Figure 24 Maxillary occlusal

09/01/2015

Figure 11 Frontal

Figure 12 Mandibular occlusal

Figure 27 Maxillary occlusal

Figure 28 Frontal

Figure29 Mandibular occlusal

Discussion and Results

Clear aligner therapy is a relatively new way of treating minor orthodontic cases. Technology
has capitalised on the orthodontic philosophy and is currently driving the scope and manner of
clinical practice, e.g. cone beam computed tomography, self-ligation brackets, digital
impression systems etc.4 Ackerman issued pertinent caution on the influence of technology on
orthodontic treatment when he stated that it is time to power down the high technology devices
plugged into the wall socket and to power up the low tech devices situated between our ears. 5
Experienced users of the clear aligner therapy concur that while clear aligners are useful in
managing minor malocclusions, they have limitations when applied to complicated
malocclusions. There are some things the aligners do well and others not so well.6
Some advantages of using the aligners include ease of insertion and removal. The patient found
instructions provided by the aligner company easy to understand and follow. An added
advantage of CAT is its potential saving of chair time.
Problems experienced in managing this CAT case included minor cracks in the aligners and a
final occlusion that was not ideal on the right side. Minor adjustments were necessary to achieve
the final correction. Heated pliers were used to produce indentations in the aligner for the final
tooth movements. These modifications were used mainly to correct rotations. The patient had to
wear the final set of aligners at night as retainers which helped with the final occlusion. The
overall results were impressive as depicted in Figures 27 to 29.

Conclusion
The keys to solving orthodontic problems are an accurate diagnosis, appropriate treatment
planning and understanding the limitations of the different appliances that are available. In this
patient CAT proved to be an efficient modality in managing this simple and mild malocclusion
with great satisfaction from the patient. In attempting to manage a patient with CAT it is
therefore imperative that a well-designed and predictable treatment plan with sustainable results
be formulated.

References:
1. Artun J. A posttreatment evaluation of multibonded lingual appliances in orthodontics.
Eur J Orthod 1987: 9: 204-210
2. Hohoff A, Seifert E, Fillion D et al. Speech performance in lingual orthodontic patients
measured by sonography and auditive analysis. Am J Orthod Dentofacial Orthod 2003;
123: 146-52
3. ClearPath (2015, February 24) ClearPath case submission. Retrieved from
http://clearpathdental.com/case-submission.php
4. Scholtz RP. Orthodontic technolocity. Am J Orthod Dentofacial Orthod 2001: 119:
325-326
5. Ackerman MB. Six keys for making orthodontics a suitable dental speciality. Angle
Orthod 2012; 83: 1103-1103
6. Profit WR. 2013. Contemporary Orthodontics. Biomechanics, Mechanics, and
Contemporary Orthodontic Appliances. 5th edition. St Louis Mosby