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 PRINCIPLES and
BIOMECHANICS of
ALIGNER TREATMENT
This page intentionally left blank
 PRINCIPLES and
BIOMECHANICS of
ALIGNER TREATMENT
Ravindra Nanda, BDS, MDS, PhD
Professor Emeritus
Department of Orthodontics
University of Connecticut Health Center
Farmington, Connecticut, USA

Tommaso Castroorio, DDS, PhD, Ortho. Spec.

Department of Surgical Sciences, Postgraduate School of Orthodontics
Dental School, University of orino
orino, taly

Francesco Garino, MD, Ortho. Spec.

Private Practice
orino, taly

Kenji Ojima, DDS, MDSc

Private Practice
oyo, apan
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043

PRINCIPLES AND BIOMECHANICS OF ALIGNER TREATMENT, ISBN: 978-0-323-68382-1

FIRST EDITION
Copyright © 2022 by Elsevier, Inc. All rights reserved.

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 To Catherine, for her love, support, inspiration, and
encouragement.
RN

To Katia, for showing me what love is and for keeping

my feet on the ground. To Alessandro, Matilda, and
Sveva, because you made the world a brighter place.
To my friends, rancesco and Keni, for your passion,
enthusiasm, commitment, and support you are always
an eample to follow. To avi, for your trust and friend
ship, for your guidance and leadership you have trans
lated a vision into reality. t was a wonderful ourney
with you thanks for your time and for sharing your
eperience.
TC

 would like to dedicate this book to all my family with a

special thought to my dad, mentor and a visionary, who
shared with me a passion in aligner orthodontics for
 years.
FG

My thanks to rancesco and Tommaso for sharing their

friendship with me over so many years. The time  spent
writing this book with avi was amaing, like a dream
for me.  am truly grateful to my family for all of their
support.
KO
Contributors

Masoud Amirkhani, PhD Aldo iancotti, DDS MS

Institute for Experimental Physics Researcher and Aggregate Professor
Ulm University Department of Clinical Sciences and ranslational
Ulm, Germany edicine
University of ome “or ergata”
Sean K. Carlson, DMD, MS ome, taly
Associate Professor
Department of Orthodontics uan Palo ome Arano, DDS, MSc
School of Dentistry, University of the Pacic Associate Professor
San Francisco, California, USA Orthodontics Program
Universidad Autonoma de aniales
Tommaso Castroorio, DDS, PhD, Ortho. Spec. aniales, Colomia
Researcher and Aggregate Professor
Department of Surgical Sciences, Postgraduate School of Mario reco, DDS, PhD
Orthodontics Visiting Professor
Dental School, University of orino University of ’Auila
orino, taly ’Auila, taly
Orthodontics Unit Visiting Professor
San Giovanni attista ospital University of Ferrara
orino, taly Ferrara, taly

Chisato Dan, DDS uis uanca, DDS, MS, PhD

Private Practice Research Associate
Smile nnovation Orthodontics Department of Orthodontics
oyo, apan University of Geneva
Geneva, Siterland
Iacopo Ciof, DDS, PhD
Associate Professor osef Kučera, MDr., PhD
Division of Graduate Orthodontics and Centre for ultimodal Assistant Professor
Sensorimotor and Pain esearch Department of Orthodontics
Faculty of Dentistry Clinic of Dental edicine
University of oronto First edical Faculty
oronto, Ontario, Canada Charles University
Prague, Cech epulic
Daid Couchat, DDS, Ortho. Spec. Lecturer
Private Practice Department of Orthodontics
Cainet d’Orthodontie du dr Couchat Clinic of Dental edicine
arseille, France Palacý University
Olomouc, Cech epulic
ae lkhol, DDS
Senior Physician ernd . apatki, DDS, PhD
Department of Orthodontics Department Head and hair
Ulm University Department of Orthodontics
Ulm, Germany Ulm University
Ulm, Germany
rancesco arino, MD Ortho. Spec.
Private Practice
Studio Associato dottri Garino
orino, taly

vi
 Contributors vii

uca omardo, DDS, Ortho. Spec. Simone Parrini, DDS, Ortho. Spec.
hairman and Professor Research Associate
Postgraduate School of Orthodontics Department of Surgical Sciences, Postgraduate School in
University of Ferrara Orthodontics
Ferrara, taly Dental School, University of orino
orino, taly
Tianton ou, DMD, MSc
Division of Gradual Orthodontics and Centre for ultimodal Serena aera, DDS, PhD, Ortho. Spec.
Sensorimotor and Pain esearch Research Associate
Faculty of Dentistry Department of Surgical Sciences, Postgraduate School in
University of oronto Orthodontics
oronto, Ontario, Canada Dental School, University of orino
orino, taly
Kam Malekian, DDS, MSc
Private Practice ariele ossini, DDS, PhD, Ortho. Spec.
Clinica io Research Associate
adrid, Spain Department of Surgical Sciences, Postgraduate School in
Orthodontics
ianluca Mampieri, DDS, MS, PhD Dental School, University of orino
Researcher and Aggregate Professor orino, taly
Department of Clinical Sciences and ranslational edicine
University of ome “or ergata” addah Saouni, DDS, Ortho. Spec.
ome, taly Private Practice
Cainet d’Orthodontie du dr Saouni
doardo Mantoani, DDS, Ortho. Spec. andol ivage
Research Associate Sanarysurer, France
Department of Surgical Sciences, Postgraduate School in
Orthodontics Sila Schmidt, DDS
Dental School, University of orino Department of Orthodontics
orino, taly Ulm University
Ulm, Germany
Io Marek, MDr., PhD
Assistant Professor ör Schare, DDS, PhD, Ortho. Spec.
Department of Orthodontics Private Practice
Clinic of Dental edicine ieferorthopädische Prais Dr örg Schare
Palacý University Cologne, Germany
Oloumouc, Cech epulic
onsultant iuseppe Siciliani, MD, DDS
Department of Orthodontics hairman and Professor
Clinic of Dental edicine School of Dentistry
First edical Faculty University of Ferrara
Charles University Ferrara, taly
Prague, Cech epulic
Ali Tassi, Sc, DDS, MClD Ortho
aindra anda, DS, MDS, PhD Assistant Dean and hair
Professor Emeritus Division of Graduate Orthodontics
Division of Orthodontics Schulich School of edicine and Dentistry
Department of Craniofacial Sciences he University of estern Ontario
University of Connecticut School of Dental edicine ondon, Ontario, Canada
Farmington, Connecticut, USA
ohnn Tran, DMD, MClD
Keni Oima, DDS, MDSc Division of Graduate Orthodontics
Private Practice Schulich School of edicine and Dentistry
Smile nnovation Orthodontics he University of estern Ontario
oyo, apan ondon, Ontario, Canada
viii Contributors

laio rie, DDS, MDentSc enedict ilmes, DDS, MSc, PhD

onn rthodontics Alumnianda rthodontics Professor
Endoed hair Department of Orthodontics
Program Director and Chair University of Düsseldorf
Division of Orthodontics Düsseldorf, Germany
Department of Craniofacial Sciences
University of Connecticut
School of Dental edicine
Farmington, Connecticut, USA

Aligners represent the new frontier in the art and science of
orthodontics. This new frontier offers new opportunities
and challenges, but also requires the need for additional
knowledge. A rethinking of biomechanics and force deliv-
ery concepts is needed along with the role of materials used
for aligners. There is a need for combining established con-
cepts with new tools and technologies which aligner treat-
ment requires.
When considering new methodologies, orthodontists
should always remember that technology is a tool and not
the goal. Diagnosis, treatment plan, and biomechanics are
always the key elements of successful treatment, regardless
of the treatment methodology. Aligner orthodontics is quite
different than traditional methods with brackets and wires.
orce delivery with aligners is through plastic materials.
Thus, the knowledge of the aligner materials, physical
properties, attachment design, and the sequentialiation
protocol is crucial for treatment of malocclusions. t is also
imperative to understand limitations of aligner treatment
and how to overcome them with the use of miniscrews and
auiliaries.
Foreword
Aligner treatment requires new knowledge the number
of clinical and scientic reports about all the different as-
pects of aligner orthodontics is increasing year by year. This
book represents an up-to-date summary of the available
research in the eld as well as a clinical atlas of treated pa-
tients based on the current evidence. We have made an
attempt to provide benchmark for clinicians, researchers,
and residents who want to improve their skills in aligner
orthodontics.
We would like to epress our great appreciation to all the
friends and colleagues who have contributed to this book. t
was a pleasure to work with all these talented orthodon-
tists.
We would like to say thank you to the lsevier team for
their support, patience, and guidance during the challeng-
ing ovid pandemic.
avindra anda
Tommaso astroorio
rancesco arino
eni ima
ix
Contents

1 Diagnosis and Treatment Planning in the 12 The rid Approach in Class  Malocclusions
Three-Dimensional Era 1 Treatment 13
TOMMASO CASTROFLORIO, SEAN K. CARLSON, and FRANCESCO GARINO, TOMMASO CASTROFLORIO, and
FRANCESCO GARINO SIMONE PARRINI

2 Current Biomechanical Rationale Concerning 13 Aligners and mpacted Canines 1

Composite Attachments in Aligner
Orthodontics 13
JUAN PABLO GOMEZ ARANGO
3 Clear Aligners: Material tructures and
Properties 3
MASOUD AMIRKHANI, FAYEZ ELKHOLY, and BERND G. LAPATKI
4 nuence o ntraoral actors on Optical and
Mechanical Aligner Material Properties 3
FAYEZ ELKHOLY, SILVA SCHMIDT, MASOUD AMIRKHANI, and
BERND G. LAPATKI
5 Theoretical and Practical Considerations in
Planning an Orthodontic Treatment ith Clear
Aligners 
TOMMASO CASTROFLORIO, GABRIELE ROSSINI, SIMONE PARRINI
6 Class  Malocclusion 1
MARIO GRECO
7 Aligner Treatment in Class  Malocclusion
Patients 
TOMMASO CASTROFLORIO, WADDAH SABOUNI, SERENA RAVERA,
and FRANCESCO GARINO
8 Aligners in Etraction Cases 3
KENJI OJIMA, CHISATO DAN, and RAVINDRA NANDA
9 Open-Bite Treatment ith Aligners 
ALDO GIANCOTTI and GIANLUCA MAMPIERI
EDOARDO MANTOVANI, DAVID COUCHAT,
TOMMASO CASTROFLORIO
14 Aligner Orthodontics in Prerestoratie
Patients 1
KENJI OJIMA, CHISATO DAN, and TOMMASO CASTROFLORIO
15 oncompliance pper Molar Distaliation
and Aligner Treatment or Correction o Class 
Malocclusions 1
BENEDICT WILMES and JÖRG SCHWARZE
16 Clear Aligner Orthodontic Treatment o Patients
ith Periodontitis 
TOMMASO CASTROFLORIO, EDOARDO MANTOVANI, and
KAMY MALEKIAN
17 urger irst ith Aligner Therap 3
FLAVIO URIBE and RAVINDRA NANDA
18 Pain During Orthodontic Treatment: Biologic
Mechanisms and Clinical Management 
TIANTONG LOU, JOHNNY TRAN, ALI TASSI, and IACOPO CIOFFI
19 Retention and tailit olloing Aligner
Therap 
JOSEF KUČERA and IVO MAREK
20 Oercoming the imitations o Aligner
Orthodontics: A rid Approach 
LUCA LOMBARDO and GIUSEPPE SICILIANI

10 Deep Bite 1 nde 

LUIS HUANCA, SIMONE PARRINI, FRANCESCO GARINO, and
TOMMASO CASTROFLORIO

11 nterceptie Orthodontics ith Aligners 11

TOMMASO CASTROFLORIO, SERENA RAVERA, and
FRANCESCO GARINO

x
 1 Diagnosis and Treatment
Planning in the
Three-Dimensional Era
TOMMASO CASTROFLORIO, SEAN K. CARLSON,
and FRANCESCO GARINO
Introduction
rthodontics and dentofacial orthopedics is a specialty area
of dentistry concerned with the supervision, guidance, and
correction of the growing or mature dentofacial structures,
including those conditions that reuire movement of teeth
or correction of malrelationships and malformations of
their related structures and the adustment of relationships
between and among teeth and facial bones by the applica-
tion of forces andor the stimulation and redirection of
functional forces within the craniofacial comple.
To accurately diagnose a malocclusion, orthodontics has
adopted the problem-based approach originally developed
in medicine. very factor that potentially contributes to the
etiology and that may contribute to the abnormality or in-
uence treatment should be evaluated. nformation is gath-
ered through a medical and dental history, clinical eami-
nation, and records that include models, photographs, and
radiographic imaging.  problem list is generated from the
analysis of the database that contains a network of inter-
related factors. The diagnosis is established after a continu-
ous feedback between the problem recognition and the da-
tabase Fig. .. ltimately, the diagnosis should provide
some insight into the etiology of the malocclusion.
rthodontics diagnosis and treatment planning are deeply
changing in the last decades, moving from two-dimensional
 hard tissue analysis and plaster cast review toward soft
tissue harmony and proportions analyses with the support
of three-dimensional  technology.  detailed clinical e-
amination remains the key of a good diagnosis, where many
aspects of the treatment plan reveal themselves as a function
of the systematic evaluation of the functional and aesthetic
presentation of the patient.
The introduction of a whole range of digital data acuisi-
tion devices cone-beam computed tomography T,
intraoral and desktop scanner  and , and face scan-
ner F, planning software computer-assisted design and
computer-assisted manufacturing  software,
new aesthetic materials, and powerful fabrication machines
milling machines,  printers is changing the orthodon-
tic profession Fig. ..
s a result, clinical practice is shifting to virtual-based
workows. Today it is common to perform virtual treat-
ment planning and to translate the plans into treatment
eecution with digitally driven appliance manufacture and
placement using various  techniues from
printed models, indirect bonding trays, and custom-made
brackets to robotically bend wires or aligners. Furthermore,
it is becoming possible to remotely monitor treatment and
to control it.5
The introduction of aligners in the orthodontics eld
led the digital evolution in orthodontics. The two nouns
evolution and revolution both refer to a change; however,
there is a distinctive difference between the change im-
plied by these two words. volution refers to a slow and
gradual change, whereas revolution refers to a sudden,
dramatic, and complete change. hat has been claimed
as the “digital revolution” in orthodontics should be
claimed as the “digital evolution” in orthodontics. rtho-
dontics and biomechanics have always had the same
denitions, and we as clinicians should remember that
technology is an instrument, not the goal. This differenti-
ates orthodontists from marketing people.
The diagnosis and problem list is the framework that dic-
tates the treatment obectives for the patient. nce formu-
lated, the treatment plan is designed to address those obec-
tives. n aligner orthodontics,  software displays
treatment animations, helping the clinician to visualie the
appearance of teeth and face that is desired as treatment
outcome; however, those animations should be decon-
structed by the orthodontist frame by frame or stage by
stage, to dene how to address the treatment goal from me-
chanics to seuence. nly an accurate control of every sin-
gle stage of the virtual treatment plan can produce reliable
results. s usual, it is the orthodontist rather than the tech-
niue itself that is responsible for the treatment outcome.
ontemporary records should facilitate functional and
aesthetic  evaluation of the patient.
Intraoral Scans and Digital
Models
s are uickly replacing traditional impressions and plas-
ter models. These scanners generally contain a source of
risk for inaccuracy because multiple single  images are
assembled to complete a model. ecent studies, however,
have shown that the trueness and precision of s of com-
mercially available scanning systems are ecellent for orth-
odontic applications. igital models are as reliable as tradi-
tional plaster models, with high accuracy, reliability, and
reproducibility Fig. ..
1
2 Principles and Biomechanics of Aligner Treatment

Database

Clinical examination
Chief complaint
Medical history
Models Photographs Radiographic imaging
Dental history
Intraoral scan 3-D facial scan CBCT
Extraoral exam
Intraoral exam
Functional exam

Problems

Problem List

Mechanics
plan:
Synthesis Treatment which movements Staging Treatment Virtual setup Treatment
and diagnosis objectives with which definition prescription Virtual patient re-evaluation
auxiliaries
Fig. 1.1 Steps in diagnosis and treatment planning in the digital orthodontics era. (Modied from Uribe FA, Chandhoe
TK, Nanda R. Indiidaied orhodoni dianoi. In Nanda R, ed. Esthetics and Biomechanics in Orthodontics. nd ed.
S Loi, MO Eeier Sander .

Fig. 1.2 Integration of cone-beam computed tomography data, facial three-dimensional scan, digital models from
intraoral scans, and virtual orthodontic setup. Courtesy of dr. Alain Souchet, ulhouse, rance.
 1 • iagnosis and Treatment Planning in the Three-imensional ra
B
Fig. 1.3 A igital models and measurements obtained from cone-beam computed tomography data. B igital
models and measurements obtained from intraoral scans.
Furthermore, the models can also be used in various
orthodontic software platforms to allow the orthodontist
to perform virtual treatment plans and eplore various
treatment plans within minutes as opposed to epensive
and time-consuming diagnostic setups and waups. er-
forming digital setups not only allows the clinician to e-
plore a number of treatment options in a simple manner
but also facilitates better communication with other den-
tal professionals, especially in cases that reuire combined
orthodontic and restorative treatments. The virtual treat-
ment planning also allows for better communication with
patients and allows them to visualie the treatment out-
come and understand the treatment process.5
Further advantages of virtual models of the dental
arches are related to study model analysis, which is an es-
sential step in orthodontic diagnostics and treatment plan-
ning. ompared to measurements on physical casts using a
3
measuring loop andor caliper, digital measurements on
virtual models usually result in the same therapeutic deci-
sions as evaluations performed the traditional way. Fur-
thermore, with their advantages in terms of cost, time, and
space reuired, digital models could be considered the new
gold standard in current practice.
igital impressions have proven to reduce remakes and
returns, as well as increase overall efciency. The patient
also benets by being provided a far more positive eperi-
ence. urrent development of novel scanner technologies
e.g., based on multipoint chromatic confocal imaging and
dual wavelength digital holography will further improve
the accuracy and clinical practicability of .
ecently near infrared  technology has been inte-
grated in . The  is the region of the electromagnetic
spectrum between . and  mm Fig. .. The interaction
of specic light wavelengths with the hard tissue of the
4 Principles and Biomechanics of Aligner Treatment

NIRI - A reflective concept of light and its mechanism of action

The iTero Element 5D intraoral NIRI image of a healthy tooth

scanner uses light of 850nm that
penetrates into the tooth structure to
produce a NIRI image

Image interpretation - Healthy tooth

Enamel is mostly
transparent to
NIRI and appears
dark

Dentin is mostly
scattering
to NIRI and
appears bright

Image interpretation - Tooth with caries

ealthy enamel
appears dark

roimal carious
lesions of the
enamel appears
bright

A
Fig. 1.4 e generation of intraoral scanners ith integrated near infrared I technology. A Itero lement 
Align Technology, San osé, CA, SA decays detection scheme.
 1 • iagnosis and Treatment Planning in the Three-imensional ra
B
Fig. 1.4, cont’ B Shape Trios  Shape AS, Copenhagen, enmar uorescent technology for surface decay
detection (left) and I technology for interproimal decay detection (right).
tooth provides additional data of its structure. namel is
transparent to  due to the reduced scattering coefcient
of light, allowing it to pass through its entire thickness and
present as a dark area, whereas the dentin appears bright
due to the scattering effect of light caused by the orienta-
tion of the dentinal tubules. ny interferencespathologic
lesionsareas of demineraliation appear as bright areas in
a  image due to the increased scattering within the re-
gion. Therefore  provides information regarding possible
decays without any -ray eposure.
Through the use of digital impression making, it has
been determined that laboratory products also become
more consistent and reuire less chair time at insertion.
3D Imaging
CONE-BEAM COMPUTED TOMOGRAPHY
 imaging has evolved greatly in the last two decades and
has found applications in orthodontics as well as in oral and
maillofacial surgery. n  medical imaging, a set of ana-
tomic data is collected using diagnostic imaging euip-
ment, processed by a computer and then displayed on a 
monitor to give the illusion of depth. epth perception
causes the image to appear in . ver the last 5 years,
T imaging has emerged as an important supplemental
radiographic techniue for orthodontic diagnosis and treat-
ment planning, especially in situations that reuire an un-
derstanding of the comple anatomic relationships and
surrounding structures of the maillofacial skeleton. From
the introduction of the cephalostat, roadbent stressed the
need for a perfect matching of the lateral and posteroante-
rior -rays to obtain a perfect  reproduction of the
skull. T imaging provides uniue features and advan-
tages to enhance orthodontic practice over conventional
etraoral radiographic imaging. ateral cephalometrics
provides information on the sagittal and vertical aspects of
the malocclusion with little contribution about unilateral
or transversal discrepancies. The latter seem to be related to
5
urbaniation and industrialiation becoming more freuent
in the last decades.-5 Therefore, the need for a diagnostic
tool providing information on the  aspects of the dento-
skeletal malocclusion is increasing. hile the clinical ap-
plications span from evaluation of anatomy to pathology of
most structures in the maillofacial area, the key advantage
of T is its high-resolution images at a relatively lower
radiation dose.
posing patients to -rays implies the eistence of a
clinical ustication and that all the principles and proce-
dures reuired to minimie patient eposure are consid-
ered. The  concept should always be kept in mind
 is an acronym used in radiation safety for as low as
reasonably achievable. This concept is supported by profes-
sional organiations as well as by government institu-
tions.  ecogniing that diagnostic imaging is the single
greatest source of eposure to ioniing radiation for the 
population that is controllable, the ational ommission
on adiation rotection and easurements has introduced
a modication of the  concept.  represents
as low as diagnostically acceptable. mplementation of this
concept will reuire evidence-based udgments of the level
of image uality reuired for specic diagnostic tasks as
well as eposures and doses associated with this level of
uality. ittle research is currently available in this area.
For  imaging modalities used in orthodontics, the ra-
diation dose for panoramic imaging varies between  and
 µv, while a cephalometric eam range is between  and
5 µv.  full mouth series ranges from  to 5 µv based
on the type of collimation used. hile  and  radia-
tion doses are often compared for reference, they cannot
truly be compared because the acuisition physics and the
associated risks are completely different and cannot be
euated. The actual risk for low-dose radiographic proce-
dures such as maillofacial radiography, including T, is
difcult to assess and is based on conservative assumptions
as there are no data to establish the occurrence of cancer
following eposure at these levels. owever, it is generally
accepted that any increase in dose, no matter how small,
 Principles and Biomechanics of Aligner Treatment
results in an incremental increase in risk. Therefore there
is no safe limit or safety one for radiation eposure in orth-
odontic diagnostic imaging.  recent meta-analysis about
the effective dose of dental T stated that the mean adult
effective doses grouped by eld of view F sie were
 µv large,  µv medium, and  µv small.
ean child doses were 5 µv combined large and me-
dium and  µv small. arge differences were seen
between different T units.
The merican ental ssociation ouncil on cientic
ffairs  proposed a set of principles for consideration
in the selection of T imaging for individual patient care.
ccording to the guidelines, clinicians should perform radio-
graphic imaging, including T, only after professional
ustication that the potential clinical benets will out-
weigh the risks associated with eposure to ioniing radia-
tion. owever, T may supplement or replace conven-
tional dental -rays when the conventional images will not
adeuately capture the needed information.
ecently, a number of manufacturers have introduced
T units capable of providing medium or even full F
T acuisition using low-dose protocols. y adustments
to rotation arc, m, kp, or the number of basis images or
a combination thereof, T imaging can be performed at
effective doses comparable with conventional panoramic
eaminations range, – µv. This is accompanied by
signicant reductions in image uality; however, viewer
software can be helpful in improving the clinical eperience
with low-uality images. ven at this level, child doses have
been reported to be, on average,  greater than adult
doses. The use of low-dose protocols may be adeuate for
low-level diagnostic tasks such as root angulations.
BENEFT OF CBCT FOR ORTHODONTC
AEMENT
The benets of T for orthodontic assessment include
accuracy of image geometry. T offers the distinct ad-
vantage of  geometry, which allows accurate measure-
ments of obects and dimensions. The accuracy and reli-
ability of measurements from T images have been
Fig. 1.5 Cone-beam computed tomography data elaboration for enhancing diagnosis and treatment planning.
demonstrated, allowing precise assessment of unerupted
tooth sies, bony dimensions in all three planes of space,
and even soft tissue anthropometric measurements—
things that are all important in orthodontic diagnosis and
treatment planning.-
The accurate localiation of ectopic, impacted, and su-
pernumerary teeth is vital to the development of a patient-
specic treatment plan with the best chance of success.
T has been demonstrated to be superior for localiation
and space estimation of unerupted maillary canines com-
pared with conventional imaging methods.5  ne study
indicated that the increased precision in the localiation of
the canines and the improved estimation of the space con-
ditions in the arch obtained with T resulted in a differ-
ence in diagnosis and treatment planning toward a more
clinically orientated approach.5 T imaging was proven
to be signicantly better than the panoramic radiograph in
determining root resorption associated with canine impac-
tion.  ne study supported improved root resorption
detection rates of  with the use of T when com-
pared with  imaging. hen used for diagnosis, T
has been shown to alter and improve the treatment recom-
mendations for orthodontic patients with impacted or
supernumerary teeth. 
ased on the ndings of a recent review and in accor-
dance with the T entomaillofacial aediatric
maging n nvestigation Towards ow ose adiation
nduced isks proect, T can be considered also in
children for diagnosis and treatment planning of impacted
teeth and root resorption Fig. .5.
aillary transverse deficiency may be one of the
most pervasive skeletal problems in the craniofacial re-
gion. ts many manifestations are encountered daily by
the orthodontist.
lthough many analyses of the lateral cephalometric
headlm have been developed for use in orthodontic and
orthognathic treatment planning, the posteroanterior
cephalogram has been largely ignored. The diagnosis of
transverse discrepancy is uite challenging in the daily
practice because of several methodologic limitations of the
proposed methods.
 1 • iagnosis and Treatment Planning in the Three-imensional ra
Fig. 1. Case of impacted loer canine in hich the cone-beam computed tomography data are helpful in dening
the right mechanics.
The maillary and mandibular skeletal widths at differ-
ent tooth level, buccolingual inclination of each tooth, and
root positions in the alveolar bone can be determined and
evaluated from the T Fig. .. ith this information,
the clinician can make a proper diagnosis and treatment
plan for the patient.
The temporomandibular oint T can be assessed for
pathology more accurately with T images than with
conventional radiographs. The T volume for orthodon-
tic assessment will generally include the T and therefore
is available for routine review. everal retrospective analy-
ses of T volumes indicate 5 to  of incidental
ndings are related to T Fig. ., which is signicant
enough for further follow-up or referral.
T data can also be used to obtain the volumetric ren-
dering of the upper airways. tudies of the upper airway
based on T scans are considered to be reliable in dening
the border between soft tissues and void spaces i.e., air,
thus providing important information about the morphol-
ogy i.e., cross-sectional area and volume of the pharyngeal
airway5 Fig. .. owever, despite the potentials offered
by the techniue in this eld and the potential role of ortho-
dontists as sentinel physicians for sleep breathing disorders,
limited, poor uality, and low evidence level literature is
available on the effect of head posture and tongue position
on upper airway dimensions and morphology in  imag-
ing. atural head position at T acuisition is the sug-
gested standardied posture. owever, for repeatable mea-
sures of upper airway volumes it may clinically be difcult to
obtain. ndications and methods related to tongue position
and breathing during data acuisition are still lacking. Fur-
thermore, a recent study focusing on the reliability of air-
way measurements stated that the oropharyngeal airway
volume was the only parameter found to have generalied
ecellent intra-eaminer and inter-eaminer reliability.
n orthognathic surgery, igital maging and ommuni-
cations in edicine  data from T can be used to
fabricate physical stereolithographic models or to generate
virtual  models. The  reconstructions are etremely
useful in the diagnosing and treatment planning of facial

asymmetry cases. They can also be used to generate substi-
tute grafts when warranted. T can be useful as a valu-
able planning tool from initial evaluation to the surgical
procedure and then the correction of the dental component
in the surgery-rst orthognathic approach.
n addition, databases may be interfaced with the ana-
tomic models to provide characteristics of the displayed tis-
sues to reproduce tissue reactions to development, treat-
ment, and function. The systematic summariation of the
results presented in the literature suggests that computer-
aided planning is accurate for orthognathic surgery of the
mailla and mandible, and with respect to the benets to
the patient and surgical procedure it is estimated that
computer-aided planning facilitates the analysis of surgical
outcomes and provides greater accuracy Fig. ..
 recent systematic review was conducted to evaluate
whether T imaging can be used to assess dentoalveolar
relationships critical to determining risk assessment and
help determine and improve periodontal treatment needs in
patients undergoing orthodontic therapy. The conclusion
was that pretreatment orthodontic T imaging can as-
sist clinicians in selecting preventive or interceptive peri-
odontal corticotomy and augmentation surgical reuire-
ments, especially for treatment approaches involving buccal
tooth movement at the anterior mandible or maillary pre-
molars to prevent deleterious alveolar bone changes. This
assumption seems more suitable for skeletally mature pa-
tients presenting with a thin periodontal phenotype prior to
orthodontic treatment Fig. ..
3D FACA RECONTRUCTON TECHNUE
The accurate acuisition of  face appearance character-
istics is important to plan orthognathic surgery, and ecel-
lent work is based on an eact  face modeling.  precise
approach to  digital face prole acuiring, which is ap-
plied to simulate and design an optimal plan for face sur-
gery by modern technologies such as , is reuired.
Three types of  face modeling methods are currently
used to etract human face proles T technology, 
 Principles and Biomechanics of Aligner Treatment

Fig. 1. ccasional report of misunderstood right condyle nec fracture results in a -year-old child being pre-
scribed cone-beam computed tomography for orthodontic reasons.

Fig. 1. Airay measurements from cone-beam computed tomography data.

 1 • iagnosis and Treatment Planning in the Three-imensional ra
Fig. 1. ample of cone-beam computed tomography data integration in a surgery three-dimensional planning
softare. (ohin Imain, Chaorh, CA, USA.
the passive optical  sensing techniue, and the active
optical  sensing techniue. The  reconstruction
method based on T technology is sensitive to the skeleton
and can be conveniently utilied for craniofacial plastics,
as well as the oral and maillofacial correction of abnor-
malities. oft tissue data etraction, or segmentation,
can be created using a dedicated software. For orthodontic
purposes, the image should be recorded with eyes open
and with the patient smiling. The smiling image will per-
mit the use of dental landmarks to superimpose the digital
models on the  face reconstruction for treatment plan-
ning purposes. ovel technologies aiming at acuiring
facial surface are available. tereophotogrammetry and
laser scanning allow operators to uickly record facial
anatomy and to perform a wider set of measurements5
not eposing patients to radiation Fig. .. tereopho-
togrammetry still represents the gold standard with
respect to laser scanning at least for orthodontic applica-
tions since it is characteried by good precision and repro-
ducibility, with random errors generally less than
 mm.5 ith this method,  images are acuired by
combining photographs captured from various angles
with synchronous digital cameras, with the main advan-
tage of reducing possible motion artifacts. The main limi-
tation at this stage is represented by the high cost of the
instrumentation.
ccording to arver and acobson and arver and ck-
erman, it may be inappropriate to place everyone in the
same esthetic framework and even more problematic to at-
tempt this based solely on hard tissue relationships since the
soft tissues often fail to respond predictably to hard tissue
changes. ntegrating T data, facial  reconstruction,

and digital models with specic simulation software will
provide useful indications in relation to orthodontic treat-
ment results and the eventual need of interdisciplinary in-
tervention.
RTUA ETUP
everal software programs are available on the market to
create virtual setups able to produce the seuence of physi-
cal models on which thermoforming plastic foils are used to
create aligners.
etup accuracy is improved when virtual teeth segmen-
tation is applied on digital models obtained by  or digiti-
ation of plaster casts, reducing the loss of tooth structure
observed during the cutting process of the plaster in con-
ventional plaster and wa setups.
The segmentation process starts with marking mesial
and distal points on each tooth or simply indicating the
center of the crown on the occlusal view of the arches, de-
pending on the software used. Then the software generally
identies the gingival margin. Teeth segmentation and the
tooth-tooth-gingiva segmentation are eecuted semiauto-
matically, but the operator can always correct the auto-
matic process. nce teeth are segmented they are separated
from the gingiva, and a mean virtual root shape and
length are derived from proprietary databases is applied.
ecently, virtual setup software programs are starting to
use real root morphologies derived from patient T data
when available. Tooth segmentation from T images
in those cases is a fundamental step. ecent engineering
innovations made the process simple and timesaving with
respect to the past.
1 Principles and Biomechanics of Aligner Treatment

Fig. 1.1 Cone-beam computed tomography data used to plan an orthodontic epansion in a subect ith poor
periodontal support (upper). rthodontic epansion, corticotomies, and bone grafts ere planned to obtain an e-
cellent nal result ithout bone dehiscence (lower)

A B
Fig. 1.11 Stereophotogrammetry A and laser scan B three-dimensional reconstructions of the face of the same
patient. (From Gibei , iarei , oa , e a. Threedimeniona faia anaom eaaion reiabii of aer
anner oneie an roedre in omarion ih ereohoorammer. J Craniomaxillofac Surg. 
.
 1 • iagnosis and Treatment Planning in the Three-imensional ra 11

Fig. 1.12 Superimposition of the virtual setup on the smile picture of a patient ith unilateral agenesis, visualiing
from left to right the initial situation, the postorthodontic situation, and the nal smile ith restorative simulation.

nce the teeth have been segmented and the interproi-
mal contacts dened, the arch form is adusted using soft-
ware tools that can create an individual arch form. igital
arch templates are also available, while several software pro-
grams consider the  an acronym for ill ndrews
and arry ndrews ridge.
The occlusal plane as well as the original vertical plane
are used as reference. ach tooth can be moved in the
space since the reuired nal position has been achieved. t
is important to mention that tooth movements on comput-
ers are unlimited. Tooth alignment and leveling can be
planned on the computer screen, but this result may not be
realistic for that specic patient. bviously, tooth movement
has its biologic limitations. n the basis of the used system
the virtual setup could be prepared by a trained dental tech-
nician or by a software epert; however, every setup should
be based on biologic principles and on a biomechanics
background making the orthodontist the initial designer
and the nal reviewer of every setup.
s progress in digital imaging techniues accelerates and
tools to plan medical treatments improve, the use of virtual
setups in orthodontics before and during treatment will
become the mainstream in orthodontics Fig. ..
novel  superimposition techniues, clinicians are able to
simulate the outcome of both the osseous structures and
the soft tissue posttreatment.
The  data integration makes the diagnostic process
and the treatment planning more accurate and complete,
provides an effective communication tool and a method for
patients to visualie the simulated outcomes, instills moti-
vation, and encourages compliance to achieve the desired
treatment outcome Fig. ..
hat technology is providing to orthodontists is ama-
ing; however, what is still missing is the fourth dimension
i.e., the dynamic movements of the mandible and the sur-
rounding tissues integrated in the virtual model. dealisti-
cally, the capture of digital data for virtual modeling should
happen in a one-step, single-device approach to improve
accuracy. Future research will ll this gap and will realie
the dream of the real virtual patient.

3D DATA NTEGRATON
The creation of a virtual copy of each patient is dependent
upon the integration of  media les and the possibility
of their fusion into a uniue and replicable model. T
data can be used as a platform onto which other inputs can
be fused with acceptable clinical accuracy. These data
sources include light-based surface data such as photo-
graphic facial images and high-resolution surface models
of the dentition produced by direct scans intraorally or in-
directly by scanning impressions or study models. The inte-
gration of hard and soft tissues can provide a greater un-
derstanding of the interrelationship of the dentition and
Fig. 1.13 The virtual patient in hich cone-beam computed tomogra-
soft tissues to the underlying osseous frame. ndividual phy data, facial three-dimensional reconstruction, and virtual setup
 models of tooth are needed for the computer-aided obtained after teeth segmentation are superimposed. Courtesy of dr.
orthodontic treatment planning and simulation. ith the Alain Souchet, ulhouse, rance.
12 Principles and Biomechanics of Aligner Treatment
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 2 Current Biomechanical
Rationale Concerning
Composite Attachments
in Aligner Orthodontics
JUAN PABLO GOMEZ ARANGO
Introduction
he orthodontic techniue that we now call “aligner or-
thodontics” has evolved considerably over the last 
years. mprovements in behavior of aligner plastics, treat-
ment planning software, and three-dimensional 3
printing have served one basic but fundamental inten-
tion to mitigate the biomechanical limitations inherent
to aligner-based tooth movement. nother signicant
development designed to overcome the aforementioned
biomechanical shortcomings of aligner systems has been
the continuous improvement of biomechanically comple-
mentary composite attachments. ttachments were con-
ceived to produce supplementary force vectors that, when
applied to teeth by the aligner material, transform the
resultant system, allowing complex tooth movements.
he application of one of the initial geometric congura-
tions was initially presented by the clinical team from
lign echnology nc., as basic  x 3 mm rectangular
structures, bonded to the lower incisor buccal surface, in
an attempt at controlling undesired tipping during space
closure after incisor extraction ig. .. s the
incisors adacent to the extraction space begin to incline
mesially, the rigid, xed structure of the attachment
collides with aligner plastic, producing force couples that
counteract the initial moment, reducing undesired tip-
ping see ig. ..
rthodontic tooth movement with conventional bracket
techniues can deliver sophisticated force systems due to
the manner in which the rigid ligature-archwire-bracket
scheme “grasps” the malaligned tooth. his particular
arrangement allows broad control of magnitude and direc-
tion of applied force vectors, and, conseuentially, of tooth
movement ig. ..
t is important to keep in mind that attachments work,
not as active agents that produce forces, but by passively
“getting in the way” of plastic as it elastically deforms due
to lack of coincidence between tooth position and aligner
material “mismatch”, establishing the force vector that
subseuently affects the tooth ig. .3.
iomaterials used for attachment fabrication must as-
sure that reuirements in adhesion, wear resistance, and
esthetics are fullled.  recent study suggests that con-
temporary microlled resin composites provide sufcient
wear resistance to deliver a stable attachment shape
during treatment, assuring its functionality. Mantovani
et al.3 also concluded that the use of bulk-lled resins for
attachment fabrication improved dimensional stability
when compared to low-viscosity resins, which experience
higher polymerization shrinkage. he use of translucent
composites generally provides sufcient esthetic accep-
tance and stain resistance as long as an adeuate bonding
techniue is executed, in which voids bubbles in attach-
ment surface and excessive residue ash left on tooth
surface are avoided.
everal considerations come into play when determining
the optimal attachment design for a specic clinical obec-
tive geometry, location, and size.
Geometry (Active Surface
Orientation)
t the time of aligner insertion, orthodontic forces will be
produced in response to the particular complex pattern of
mismatches between plastic and tooth structure. his pat-
tern of mismatch–plastic deformation–orthodontic force is
critical for attachment design during digital simulation to
produce specic areas active surfaces that will contact
aligner plastic with predetermined force magnitudes,
producing the desired force vectors and conseuent tooth
movements. ot all the surface area of attachments will be
in direct contact with the aligner. he active or functional
surfaces can and should be determined with thoughtful
biomechanical intentionality, in accordance with clinical
obectives ig. .. hile the magnitude of the force
produced is determined by the amount of mismatch along
with the characteristics of aligner material, the direction
of the force will depend on the orientation of the active
surface. he principles of mechanics state that the direction
of the normal component of the contact force the vector
that in this case acts upon the active surface of the attach-
ment will always be perpendicular to that surface see
ig. .. dentifying the direction of these complemen-
tary force vectors is essential for treatment planning, espe-
cially when more than one force acts simultaneously. n
these cases, the resultant forces must be properly recog-
nized to deliver predictable tooth movements see ig. ..
13
14 Principles and Biomechanics of Aligner Treatment
B Fig. 2.3 (A) Alignertooth mismatch. (B) lastic aligner deformation
Fig. 2.1 (A) Mesial tipping moments (red curved arrows) produced by
aligner forces (red arrows) occurring during space closure. Antitipping
moments (blue curved arrows) produced by forces (blue arrows) acting
at rectangular vertical attachments (B). Opposing moments are
canceled out, promoting bodily movement.
Fig. 2.2 The typical force couple generated during bracetbased
alignment of rotated tooth ith a fully engaged . iTi archire
consists of to force vectors one that pushes against the posterior
all of the slot (red arrow) and a second that pulls aay from the same
all (blue arrow)
C
and activation of forces upon aligner insertion. () Tooth alignment
after aligner seuence.
Location
ased on the premise that the magnitude of a moment is
proportional to the perpendicular distance between the line
of action and the center of resistance, to fully understand
the effect of aligner-based orthodontic forces being applied
in any particular moment, it is essential to establish this
distance in the three planes of space. nce this correlation
has been clearly established and uantied, there will be a
much clearer picture of the effectiveness of expected
rotational moments as well as the possibility of anticipating
undesired occurrences such as buccolingual and mesiodis-
tal tipping and intrusion. n a case in which mesiolingual
rotation of the tooth is reuired, localization of attachment
 will produce a strong mesial tipping moment and a weak
mesiolingual rotational moment ig. .. n this specic
clinical situation, a better alternative would be with attach-
ment location , in which modication in distance from
line of action to center of resistance would reduce tipping
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics 15

A B C
Fig. 2.4 (A) Active surfaces of attachments. (B) irection of forces acting at active surfaces. () esultant force
affecting the rst premolar ill produce etrusion and clocise, secondorder rotation.

A Distal Mesial B Distal Mesial

Fig. 2.5 (A) ue to the distance beteen the center of resistance (blue dot) and the line of action (red dotted line),
large mesial tipping and negligible mesiolingual rotational moments should be epected. (B) A more mesial and
apical attachment location ill result in reduced mesial tipping and increased mesiolingual rotational moments,
increasing clinical efcacy.

tendency as well as increase mesiolingual rotational capac- Size

ity see ig. ..
nother example of the inuence of attachment local-
ization is observed during transverse arch expansion,
when buccal tipping of posterior segments is detrimental
to treatment obectives.  recent unpublished nite
element analysis  study of the mechanical effects
of the bonding position of rectangular horizontal attach-
ments found that the resultant tipping moment acting
on the molars was greater when located on the lingual
surface of the rst upper molars versus the labial surface
ig. ..
ttachment size is important because of its mechanical
and esthetic implications. mall congurations are desir-
able because they are less noticeable however, as size di-
minishes, so does the ability to produce predictable forces
due to reduced active surface area. n the other hand,
larger attachment designs are desirable because of their
increased biomechanical capabilities, but they result in in-
creased aligner retention with subseuent patient discom-
fort and negative esthetic perception, especially with high-
prole congurations in anterior teeth.
16 Principles and Biomechanics of Aligner Treatment

A B
Fig. 2.6 uring epansion, labial attachment location (A) produced smaller net buccal molar tipping moments than
lingually bonded attachments (B).

Functions nongingivally beveled such as a horizontal rectangular or

PROVIDING ALIGNER RETENTION
or aligner-based orthodontic forces to affect teeth as con-
ceived in digital simulation, the aligner must be stably
seated after insertion and remain so for the duration of
treatment. ccasionally, decient adaptation of the aligner
may occur, usually resulting from faulty fabrication, but
may also occur due to the many reactive forces produced
once properly tted. or example, as a freuent response to
intrusive forces acting on the posterior teeth, the aligner
will tend to be dislodged in the anterior segment, and vice
versa. he use of intermaxillary elastics, especially when
they are engaged directly to the aligner, will also tend to
vertically dislodge it in the direction of the elastic
force. onding retentive attachments on teeth adacent to
those receptors of the elastic force is recommended to
maintain proper aligner engagement ig. ..  study
by ones et al. suggests that the optimal attachment con-
guration, when high aligner retention is imperative, is a
occlusally beveled design, as close to the gingival margin
as possible see ig. .. s a general rule of attachment
design, occlusal beveling will facilitate aligner insertion
due to the inclined plane conguration as well as increase
force and discomfort reuired for aligner removal.
AVOIDING ALIGNER “SLIPPING”
specially when rotating rounded teeth, the sum of a se-
ries of tangential forces is responsible for tooth movement
ig. ., causing inconvenient displacement slipping
of the aligner in relation to the tooth surface, reducing the
system’s efcacy and predictability, and resulting in lack
of full expression of digitally planned rotation with the
tooth lagging behind the corresponding aligner stage.
linically, incomplete rotation and loss of tracking will be
observed, manifesting as a space between tooth and plas-
tic see ig. .. ppropriately designed attachments
can help the aligner lock in to the tooth crown, greatly
reducing this undesired slipping effect.

A B
Fig. 2.7 (A) Attachments located on teeth adacent to force application increase aligner retention hen using inter
maillary elastics. (B) Attachment position close to the gingival margin and occlusally beveled geometry is ideal for
aligner retention.
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics
A tion of the aligner material is evident. his time-dependent
B
Fig. 2.8 (A) Multiple tangential forces (red arrows) acting during
alignerbased, bicuspid rotation. (B) ue to slipping effect, incomplete
epression of epected rotation ith space beteen tooth and aligner
(in yellow) ill be observed.
DELIVERING PREDETERMINED FORCE VECTORS
he fundamental purpose of composite attachments in
aligner orthodontics is to produce specic, complementary
force vectors reuired for predictable tooth movement,
which are not possible with the sole use of aligners thermo-
formed with existing materials ig. ..
A B
Fig. 2.9 (A) Properly designed attachments produce complementary
force vectors reuired for predictable tooth movement. (B) Polymer
stress relaation and creep, along ith incomplete rotation and unin
tended force (blue arrow), may occur during seuence of aligner
based, tooth rotation stages.
17
nfortunately, to harness the full clinical potential of
bonded attachments, current polymers have yet to resolve
limitations associated with their viscoelastic and hygro-
scopic nature. nce inserted, the initial force produced by
the aligner after it is elastically deformed is not constant
and will decline with time. his time-dependent reduction
of force under constant deformation is called stress relax-
ation.  ot infreuently, due to unwarranted localized
stress caused by excessive mismatch, lack of compliance,
or shortcomings inherent to the polymer, the aligner is not
able to accommodate the attachment. hen forces exerted
upon the aligner exceed its capability to adust to the new
position, unintended forces will appear, the tooth will lag
behind, and control will be lost see ig. .. ig. .
illustrates how this phenomenon is responsible for the
incomplete expression of the expected tooth movement,
where only 3 of the  degrees of predicted rotation were
achieved after completion of the entire seuence of stages.
n this case, after the aligner is removed, plastic deforma-
plastic deformation under constant force is called creep and
is attributed to reorganization of polymer chains. t is
important to underline that this permanent deformation,
so detrimental to clinical performance of plastic aligners, is
not caused by a violation of the materials’ elastic limit but
is due to a time-dependent, mechanochemical phenome-
non of a different nature.
his inherent aw of aligner plastics is the maor cause
behind the inconsistent force levels and plastic deformation
that result in one of the most dreaded occurrences for
orthodontists practicing aligner orthodontics, now com-
monly referred to as loss of tracking. ig. . illustrates an
example of the clinical manifestations of this complex
reality in which mesiolingual rotation and extrusion of a
rst upper left bicuspid were incorporated in the digital
treatment plan but did not fully occur. he lack of coinci-
dence between the attachment and its corresponding recess
in the aligner is unambiguous evidence of loss of tracking,
a contingency that in many cases must be resolved by
obtaining updated digital dental models from which a new
treatment seuence must be designed.
Basic Attachment Conurations
in Current Ainer Orthodontics
he evolution of attachments, derived from a better under-
standing of the effect of geometry, location, and size of the
composite structure, has resulted in a diverse array of con-
gurations with well-dened biomechanical obectives.
VERTICAL CONTROL
he tendency of conventional xed orthodontics to in-
crease vertical dimension, especially in open-bite patients
with increased anterior facial height, has been studied.
ligner-based treatment has proven to be an effective
alternative for open-bite correction-3 with encouraging
results.3 uccessful treatment often includes the sum of
complementary clinical strategies such as the combined
effect of counterclockwise mandibular rotation, posterior
intrusion, and anterior extrusion.
18 Principles and Biomechanics of Aligner Treatment

A B
Fig. 2.1 (A) mage from linhec treatment plan. (B) oss of tracing ith incomplete epression of rotation and
etrusion of left upper bicuspid. ac of coincidence beteen attachment (green shaded area) and its corresponding
recess in the aligner (green outline) is observed.

ANTERIOR ETRSION
orrection of open bite based solely on anterior extrusion is
to be viewed with caution because of possible negative ef-
fects such as root resorption, periodontal deterioration, in-
stability, and unfavorable esthetics.  long with these
clinical restrictions, aligner extrusion poses mechanical lim-
itations in anterior teeth in which buccal and lingual crown
surfaces converge towards the incisal edge ig. ., fa-
cilitating aligner dislodgement and rendering this type of
tooth movement virtually impossible see ig. . with-
out the use of supplementary composite attachments. 
gingivally oriented, inclined plane conguration ig. .
provides a force system that improves predictability of this A
type of movement. he importance of attachment design
can be illustrated with a graphic simplication of a complex
interaction of vectors. he resultant force acting on the

A B
Fig. 2.11 (A) onverging buccal and lingual cron surfaces. (B) nde
sired aligner dislodgment during etrusive movement.
B
Fig. 2.12 (A) Optimied trusion Attachments (Align Technology,
anta lara, A) on central incisors. (B) ingivallyoriented inclined
plane ith optimal active surface angulation.
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics 19

150°
110°

A B
Fig. 2.13 (A) orces transmitted by the aligner (red arrows) and resultant forces (purple arrows) acting on the tooth.
(B) A reduction of the angle beteen active attachment surface and buccal tooth surface produces stronger resul
tant etrusive forces.

incisor is derived from the two red arrows that represent

buccal and lingual forces present during aligner-based
extrusion ig. .3. educing the angle formed by
the active surface of the attachment and the buccal surface
of the tooth will result in a stronger resultant force see
ig. .3. linicians must be wary of excessive reduction
of this angle, which along with excessive force may produce
difculty of aligner-attachment engagement with the ensu-
ing localized plastic deformation.

POSTERIOR INTRSION
ecent studies suggest that the presence of interocclusal plas-
tic during aligner treatment  may produce a bite-block ef-
fect that potentiates bite closure and posterior intrusion capa-
bilities. his improves treatment outlook, especially in cases in
which anterior extrusion is not desirable and intrusion of
posterior teeth, with the conseuent mandibular rotation, are
to be considered as part of the strategy for bite closure. s
mentioned previously, intrusive forces acting in the posterior
region will tend to dislodge the aligner in the occlusal direc- Fig. 2.14 ntrusion in the posterior segment (red arrows) produces
tion. ven with light posterior intrusive forces, an opposite, reactive forces that ill tend to dislodge the aligner anteriorly (blue
reactive force should be expected in the anterior arch that will arrows). Adeuate attachment selection on anterior teeth ill counter
tend to vertically dislodge the aligner ig. .. ingivally act this undesired occurrence.
positioned rectangular horizontal or occlusally attachments
beveled towards the incisal edge should provide the necessary
of specialized attachments, which improve biomechanical
aligner stability for optimal treatment progress.
capabilities.
he limitations associated with rounded crown
FIRSTORDER CONTROL
morphologies are due to some extent to three particular
Ri realities
otation of teeth with rounded anatomies such as bicus- n s mentioned previously, in rounded crown congura-
pids and molars is another movement particularly dif- tions, the tangential nature of the forces produced
cult to accomplish with plastic aligners without the help during aligner-based tooth rotation, along with very
2 Principles and Biomechanics of Aligner Treatment

low coefcient of friction between the two surfaces,
facilitates a slipping effect between the aligner and
tooth.
n he line of action of the normal force vectors resultant
from tangential forces delivered during rotation of
rounded crowns crosses at a short distance from the
center of resistance, resulting in weaker rotational
moments ig. .. hese difculties are overcome by
means of specically designed composite attachments,
with properly oriented active surfaces, reconguring re-
sultant force vectors with increased intervector distance
see ig. . and resulting in stronger, more effective
rotational moments. dditionally, the attachment struc-
ture blocks the slipping effect between aligner and tooth
surface, allowing a fuller expression of desired tooth
movement.
n nother effect observed in laboratory experimentation
as well as in clinical practice is unintended intrusion
during rotational tooth movement. n another study
using nite element analysis, researchers demon-
strated that during aligner-based rotation of an upper
canine without attachment, not only did the tooth lag
behind the corresponding aligner stage almost by 3,
but it also displayed clinically signicant intrusive forces
that were found to be 3. times greater without than
with attachments ig. .. he same numeric model,
from an incisal perspective, revealed distinct pressure
areas on the mesial and distal slopes of the incisal ridge
ig. ., to which this undesirable effect can be attrib-
uted and corresponds to the normal components of the
forces imparted by the aligner. ue to the orientation of
With ATT
Without ATT
30

25

Canine rotational lag (%)

20

15

10

0
0.25 1.25 2.25 3.25
A Aligner rotation (°)
With ATT
Without ATT
A
0.50
0.45
0.40
0.35
0.30
Fy (N)

0.25
0.20
0.15
0.10
0.05
0
0 0.5 1.0 1.5 2.0 2.5 3 3.5 4
B Rotation (°)
B Fig. 2.16 (A) ithout attachment, the tooth lagged behind the aligner
almost by . ith attachment incorporation, this lag dropped to
Fig. 2.15 (A) otational forces produced by the aligner (purple arrows) . (B) ntrusive forces observed at the periodontal ligament ithout
are transmitted to the tooth as normal force components (red arrows), attachments as .  for every degree of rotation, hile ith
hich are perpendicular to tooth surface tangents (purple dotted lines). attachments the load as reduced to .  for every degree. ATT,
(B) ncorporation of bonded attachment increases the magnitude and Attachment. (Adapted from óme P, Peña M, alencia , et al.
efcacy of rotational moment by increasing the perpendicular distance ffect of composite attachment on initial force system generated
(green dotted line) beteen the line of action (red dotted line) and the during canine rotation ith plastic aligners a three dimensional nite
center of resistance (es) elements analysis. J Align Orthod. .)
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics 21

Buccal

Distal Mesial

Mesial
Distal

A Lingual
Fig. 2.18 Optimied otation Attachment (Align Technology, anta
lara, A) ith active surface oriented to provide a compensatory
etrusive force.

B
Fig. 2.17 (A) igital image of occlusal vie of right upper canine.
Occlusal vie of nite element method simulation of upper right ca
nine during mesiolingual rotation. (B) istinctly intrusive pressure ar
eas (red) on mesiolabial and distolingual aspects of the tooth cron
appear upon aligner insertion. The dotted line represents the aligner’s A
prole. (Adapted from óme P, Peña M, alencia , et al. ffect of
composite attachment on initial force system generated during canine
rotation ith plastic aligners a three dimensional nite elements
analysis. J Align Orthod. .)

the surface area, these forces are clearly intrusive. his

undesirable intrusive effect can be reduced with appro-
priate attachment design, orienting the active surface at
an angle in which the normal component of the force
transmitted by the aligner will express an extrusive
tendency ig. ..

SECONDORDER CONTROL
ipping movements are easily achieved with bracket-based
biomechanics ig. .. n the other hand, aligners
lack control of mesiodistal root position due to the system’s
B
inability to produce the reuired force couples, explaining
why modication of anterior teeth angulation is so chal- Fig. 2.19 (A) orce couple produced during bracetbased correction
lenging. o improve second-order capabilities, aligner-based of ecessive mesial tip. (B) uivalent force couple produced at Opti
systems rely on specialized attachments that generate mied oot ontrol Attachments (Align Technology, anta lara, A)
during alignerbased tipping.
euivalent force couples see ig. ..
22 Principles and Biomechanics of Aligner Treatment

Ai T
uccessful closure of extraction spaces with aligners is
also particularly difcult without excessive tipping in the
direction of tooth movement. umeric models describ-
ing tooth displacement ig. . and periodontal liga-
ment  strain ig. . patterns during distal tooth
movement have shown that ptimized oot ontrol t-
tachments lign echnology, anta lara, , when
bonded to upper cuspids, produce force systems capable of
controlling undesired inclination during extraction space
closure.
Pi T
n the posterior segment, tipping movements are not easily
obtained with aligner-based mechanics without combining
xed auxiliaries such as buccal tubes, power arms, etc.,
and these tooth movements, although possible, reuire
sophisticated treatment planning, clinical expertise, and
patient cooperation. dditionally, as with most complex
force systems, specialized attachments must be designed to
A B
enhance the biomechanical capabilities of the aligner. he
goal of this conguration of composite attachments is to Fig. 2.21 Periodontal ligament strain patterns during alignerbased
produce a force couple and its corresponding moment distaliation of upper right canine. (A) ithout attachments, distocervi
cal pressure (in blue) and distoapical tension (in red) areas ere
that will incline the tooth in the desired direction observed, typical of uncontrolled distal tipping. (B) ith attachments,
ig. .. lternatively, the rectangular, horizontal uniform pressure along the distal root surface (in blue) and uniform
attachment can be replaced with two shorter attachments, tension (in red) along the medial surface, typical of distal bodily move
with variable distance separating them according to the ment, ere observed. (Adapted from ome P, Peña M, Martíne ,
clinician’s plan see ig. .. t is important to remem- et al. nitial force systems during bodily tooth movement ith plastic
aligners and composite attachments a threedimensional nite
ber that the magnitude of the moment will depend on the element analysis. Angle Orthod. .)
amount of activation and corresponding mismatch
prescribed in the digital treatment plan. n the other hand,
the magnitude of the individual force vectors acting at the

A B
Fig. 2.2 Tooth displacement patterns during alignerbased distalia
tion of upper right canine. (A) ithout attachments, distinct uncon
trolled distal tipping as observed, ith center of rotation beteen
apical and middle thirds of the root (red arrow). (B) ith attachments,
the canine epressed distal bodily movement. (Adapted from ome B
P, Peña M, Mart√≠ne , et al. nitial force systems during bodily tooth
movement ith plastic aligners and composite attachments a three Fig. 2.22 (A) prighting moment produced at single rectangular hori
dimensional nite element analysis. Angle Orthod. .) ontal attachment. (B) Alternative tin attachment conguration.
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics 23

A B
Fig. 2.23 Producing euivalent moments (curved arrows), an increase in intervector distance proportionately
reduces force magnitude (blue arrows) acting at attachment surface. To degrees of distal tipping ith a mm
rectangular attachment (A) ill produce higher forces on the aligner than ith a toattachment conguration that
signicantly separates the force vectors (B) of the acting couple.

aligner-attachment contact will depend on the distance
between these two vectors. s the distance between the vec-
tors decreases, the forces produced at the active surfaces of
the attachments to produce an eual uprighting moment
will increase ig. .3. his is an extremely important
detail, considering aligner polymers’ high susceptibility to
creep-related plastic deformation, which reuires the use of
the lowest forces possible.
Dii M
n effective strategy for controlling anchorage during ex-
traction space closure is anterior and posterior moment to
force ratio manipulation in favor of the segment that
reuires anchorage.3 s shown in ig. ., a reciprocal
moment to force ratio between anterior alpha and poste-
rior beta segments will result in group  space closure, in
which both segments will meet at the middle of the extrac-
tion space resulting in class  malocclusion see ig. ..
o obtain class  occlusion, posterior anchorage must be
reinforced. onding rectangular horizontal attachments on
the buccal surface of posterior teeth ig. . will result
in clockwise moments that will resist mesialization of
posterior teeth, resulting in group  space closure and the
desired class  occlusal outcome see ig. ..

A B
Fig. 2.24 lass  case in hich reciprocal moments beteen anterior and posterior segments during etraction
space closure (A) ill result in  anchorage loss and class  occlusion (B).
24 Principles and Biomechanics of Aligner Treatment

A B
Fig. 2.25 locise moments (blue curved arrows) produced by attachments bonded to posterior teeth (A) ill
counteract posterior anchorage loss, reducing it to , resulting in class  occlusion (B).

TIRDORDER CONTROL magnitudes reuired for third-order control are signi-

Ai T
orue modication of anterior teeth with conventional
brackets is easily achieved by means of preactivation of
the rectangular archwire, producing a complex, high-
force couple when fully engaged in the rectangular slot
ig. .. ccomplishing the same type of movement
with plastic aligners demands an euivalent couple, derived
from horizontal, parallel, and opposing forces applied on
buccal and lingual surfaces see ig. .. ecause of the
relatively ample distance between the couple vectors, force
cantly lower than those reuired in euivalent bracket-
based force systems.
Pi T
orrection of transverse deciencies by expansion of the
dental arch continues to be a challenging clinical obective
with current aligner-based techniues. his has led to a
widespread tendency of clinicians to overcorrect expansive
movements in 3 treatment planning. he main reasons
for lack of efcacy and predictability in the transverse plane
are excess buccal tipping and insufcient force levels.

A B
Fig. 2.26 (A) By preactivating (red shaded) and subseuently inserting (red) the archire, a force couple (blue ar-
rows) and its corresponding counterclocise moment (blue curved arrow) ill be produced. (B) The same positive
torue can be achieved ith aligners by producing an euivalent couple, ith loer forces and increased intervec
tor distance.
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics 25

Excess Buccal Tipping Insufcient Force Levels

ecause forces act at a distance from the molar’s center of
resistance ig. ., buccal tipping must always be ex-
pected when expansive forces are applied, especially when
aligner-based forces are used. ith negligible friction
and conseuent pervasive sliding effect between plastic
and tooth crown, and relatively low stiffness as uncon-
trolled tipping occurs during expansion, the aligner will
tend to are, losing control as dissociation between tooth
and plastic occurs see ig. ..
he use of attachments horizontal rectangular or oc-
clusally beveled bonded to the buccal surface of posterior
teeth helps improve third-order control by counteracting
the undesired tipping moment as a result of a couple with
opposite forces acting at the occlusal surface and at the
gingival aspect of the attachment ig. ..
ue to their horseshoe-shaped geometry, orthodontic
aligners deliver expansive forces in a particular manner in
which an anteroposterior decreasing force gradient will
be observed ig. .. ecause of this distinct mode of
force transmission, researchers have found that efcacy
planned vs. nal increase in arch width of upper arch
expansion dropped from  at rst premolars to  at
the second molar.  ncreasing force levels during arch
expansion by using thicker or lower elastic modulus poly-
mers for aligner fabrication would improve this shortcom-
ing, but not without the inconvenient increase in force
levels of all other tooth movements programmed during
the expansive stages. n alternative solution is the use of
intermaxillary elastics, especially in cases with reduced
anterior facial height, in which buccolingual tipping and

Lingual Buccal
Lingual Buccal

A B
Fig. 2.27 (A) Alignerbased epansive force (red arrow) applied at a distance from the center of resistance (CRes) ill
produce counterclocise moment (red curved arrow). (B) ithout preventive measures, buccal tipping ith center
of rotation (CRot) above the furcation ill occur, folloed by aligner deformation and loss of control.

Lingual Buccal Lingual Buccal

A B
Fig. 2.28 (A) Opposing forces (blue arrows) acting at the occlusal surface and gingival aspect of a rectangular hori
ontal buccal attachment ill provide a clocise moment (blue curved arrow) that reduces buccal tipping, ith
apical migration of the center of rotation (CRot) (B).
26 Principles and Biomechanics of Aligner Treatment

A B
Fig. 2.29 (A) Programmed epansive mismatch beteen aligner and dental arch. (B) Once inserted, the resultant
epansive forces ill have a distally decreasing magnitude gradient.

A B

C D
Fig. 2.3 o angle patient (A), ith bilateral posterior crossbite (B, ) and midline discrepancy ().

extrusion of posterior segments are acceptable ig. .3.
lastic forces originated from buttons bonded to palatal
upper and buccal lower aspects of molars ig. .3 will
produce a force vector with vertical and horizontal com-
ponents of clinically relevant magnitudes that must be
considered during treatment planning. n the example in
ig. .3, a -gmf vector produced by a crossed inter-
maxillary elastic will be transmitted to the system as
 gmf of horizontal and  gmf of vertical force. s
mentioned previously, horizontal rectangular attach-
ments are effective in mitigating undesired tipping by
counteracting excessive rotational moments ig. .33.
y controlling vertical and transverse force levels, as well
as desired and undesired tipping moments, predictable
aligner-based treatment of different types of transverse
discrepancies is possible ig. .3.
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics 27

A B C

Fig. 2.31 (A) nitial linhec stage. (B) Aligners inserted, prior to bonding of upper palatal and loer buccal
buttons. () rossbite elastic.

90 gmf

42 gmf
100 gmf

Fig. 2.32 A gmf intermaillary elastic force ill produce a gmf

effective transverse force, epanding the upper arch and compressing
the loer arch. Additionally,  gmf of etrusive force ill eually in§u
ence upper and loer arches.

Fig. 2.33 n the upper arch, the moments provided by upper buccal
attachments (blue curved arrows) ill counteract moments (red curved
arrows) produced by elastic epansive forces (red arrows), reducing
undesired upper tipping. n the loer arch, unopposed lingual elastic
forces (dotted red arrows) ill result in epected lingual tipping (dotted
red curved arrows)
28 Principles and Biomechanics of Aligner Treatment
A B
C
Fig. 2.34 (A, B) nitial bilateral crossbite and midline discrepancy. (, ) Alignerbased correction ith complemen
tary use of intermaillary elastics.
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 3 Clear Aligners: Material
Structures and Properties
MASOUD AMIRKHANI, FAYEZ ELKHOLY, and BERND G. LAPATKI
Introduction
The continued improement of medical treatment de-
mands easy to use, cheaper, and more durable products
without compromising the treatment outcome itself. ue
to inherent properties and aailability, polymeric materi-
als show high potential for medical applications. oly-
meric materials are lightweight, easy to manufacture,
cheap, and ersatile. These properties allow them to be
used in dierse medical applications such as implants,
prostheses, and orthodontic appliances. s of any mate-
rial used for medical applications and intraoral applica-
tions in particular, the polymer must be biocompatible
and must not induce aderse reactions., The restrictions
and the standard in choosing a polymer depend on the
type of application.
In orthodontic applications, polymers are exposed to the
intraoral enironment, which comprises seeral different
substances including water, electrolytes, enymes, bacteria,
among other components. dditionally, consuming differ-
ent food and drin changes the acidity and ion concentra-
tion and may temporarily introduce organic solent e.g.,
alcohol to the polymer enironment. This means that the
polymer must be resistant to chemical corrosion. rinci-
pally, corrosion causes a particle release, which—depending
on the sie and form of particles—might inuence the
mechanical properties of the polymer as well.
nother important aspect is the thermal properties of
the polymer. lthough the intraoral temperature remains
relatiely constant near °, a polymer could be sub-
ected to arying temperature during intraoral application.
This means that the intraoral temperature might change
from a subero range e.g. while eating ice cream to alues
as high as 6° e.g., while drining tea. uch temperature
ariations lead to expansion or contraction of the material,
which might hae an inuence on the interaction between
the polymer and the teeth. Thus, a polymer must be able to
tolerate temperature alteration without a pronounced
olume and mechanical performance change.
The mechanical stability of the polymer also plays an
important role in orthodontic applications. or instance, a
polymer used for aligners must withstand high occlusal
forces otherwise, fractures or deformation might occur. 
change in the mechanical properties of the polymer during
the intraoral application period could also lead to un-
wanted changes of the mechanical loads applied to the
teeth. en for a chemically stable material i.e., a material
showing no corrosion, the mechanical properties of the
polymer can still ary oer time due to aging and creep.5-
30
There are two types of aging: physical and chemical
aging.5 6 Both chemical and physical aging render the
polymer brittle and stiffer, thus a lower strain may be gen-
erated during the application.
This chapter will focus on the basic properties of poly-
mers typically used for aligners. It will also include an
explanation of the chemical structure and thermal prop-
erties of these polymers. s the effectieness of a polymer
for dental use depends on thermal, chemical, and me-
chanical stability, these issues also will be discussed
briey. inally, future perspecties of polymers used for
aligners are described.
Polymer Molecular Structure
and Thermal Properties
olymers are ery long and entangled molecules with non-
conentional thermal and mechanical behaior. In this
section, the structure of a polymer and its thermal behaior
will be described. This comprises the specication of glass
transition, aspects of aging, and the stability of the polymer
in the intraoral milieu.
WHAT IS A POLYMER?
The word polymer is deried originally from the ree
words poly “many” and méros “units”. This indicates
that polymers consist of many repeating units connected
to each another through chemical bonding. ormally, if a
substance contains ust a few molecules, an addition or
remoal of only a few atoms would change the material
properties signicantly. or example, if one would add ust
 to heptane 6, then the boiling point of the
resulting molecule  increases by °. ith poly-
mers, in contrast, the number of repeating units could be
changed by one or more units without any noticeable
change in the polymer properties.
Typically, a polymer chain is made of seeral thousand
repeating units with a length of seeral micrometers and a
diameter ust around  nm. The polymer chain is usually
exible, twisted, and intertwined. The molecular weight
and chemical structure of the polymer determine most of
its properties. In contrast to small molecules haing a
specic sie and molecular weight expressed in gmol or
gmol, a polymer bul contains polymer chains with
many different sies and molecular weights. ence the
molecular weight of the polymer reects an aerage of
many different polymer chains.
 3 • Clear Aligners: Material Structures and Properties 31

C C O CH2 CH2 O

O n
Fig. 3.1 Chemical structure of polyethylene terephthalate glycol material (PET).

O H O H H

C N C N C O C C O

H H HH H
n
Fig. 3.2 Chemical structure of polyurethane material (PU).

Based on their thermal behaior, the three different
classes of polymers are thermoplastic, elastomer, and
thermoset. lear aligners belong to the thermoplastic
group. Thermoplastic polymers melt and flow upon heat-
ing aboe a certain temperature. Two widely used poly-
mers for aligners are polyethylene terephthalate glycol
T- and thermoplastic polyurethane T.- The
latter is a special thermoplastic form of polyurethane
which melts by heating, facilitating the thermoforming
process. Both of these thermoplastic materials are trans-
parent in the isible light spectrum, are impact-resistant,
and highly ductile. ust these properties in particular
mae them ery suitable for use as aligner material.
T- is a copolymer that constitutes two repeating units
ig. .: polyethylene terephthalate and glycol. The addition
of glycol preents the crystalliation of the T upon heating.
This maes T- less brittle and more resistant to mechani-
cal stress. T- is a ersatile polymer used in many other
applications such as protectie coer e.g., smart card, elec-
tronic deices, food containers, and medical instruments. ne
can thermoform, print, drill, bend, polish, and cut T- easily
without noticeable impact on its stability and physical proper-
ties. s T- can be easily thermoformed and also recycled, it
is also the material of choice for three-dimensional printing.
The building bloc of polyurethane is urethane ig. ..
 is aailable in both soft and rigid form, maing it ideal for
automotie interiors, pacaging, coating, exible foam, and
construction.  is impact resistant, is a good electrical iso-
lator, bonds well with other material, and is chemically sta-
ble in the presence of water and oil. The ersatility of  is
due to the fact that one can lin urethane molecules using
ore specically, if a polymer is obsered in a short time
scale, it behaes lie a solid material. If the experiment,
howeer, is performed during a longer time period, poly-
mers may ow and show a liuidlie behaior.
This phenomenon is to be exemplied on the basis of the
behaior of a simple liuid ethanol, which normally crys-
tallies. et us assume that the liuid is cooled below its
melting point. ig. . illustrates the change of the specic
olume of the material ersus its temperature. The specic
olume, dened as olume diided by mass, is the reerse of
the density. uring cooling, the specic olume of the liuid
decreases continually as long as it is still in the liuid phase.
There exists, howeer, a point the freeing point at which
the specic olume will decrease drastically and form a
crystalline solid. uch olume discontinuity is related to the
reduction of specic olume due to the crystalliation. Be-
low the freeing point, the specic olume remains almost
constant een though the cooling process is continued. The
freeing or melting point is a material property and does not
depend on the cooling rate or method of the measurement.
It also has a clear thermodynamic denition without any
room for interpretation.
nder certain conditions, small molecules and many
types of polymers, howeer, do not follow the mentioned
uid
Liq
id
-l iqu
led
Specific volume

different chemicals in ery different structures. This allows oo

p erc
tailoring the hardness of  to the specic application. In Su
general,  is biocompatible, but to mae it applicable as
Amorphous
aligners,  is usually combined with other material.

Crystalline
GLASS TRANSITION-THE MACROMOLECULAR
BASIS OF VISCOELASTICITY
epending on the temperature, most materials exist in a
solid, liuid, or gas state. ach of these states could be pre-
cisely described by thermodynamics laws. oweer, the Temperature Tg Tm
inestigation of polymers reealed that most of them do not
follow these basic material states. Instead, they show uid Fig. 3.3 Specic olume ersus temperature. Tm represents the
melting temperature and Tg the glass transition temperature.
or solidlie, time-dependent characteristics.
32 Principles and iomechanics of Aligner Treatment
0.34
0.33
0.32
0.31
Heat flow/mass (m/m)
0.30
0.29
0.28
0.27
0.26
0.25
0.24
0.23
0.22
45 50
Fig. 3.4 ifferential scanning calorimetry of polyethylene terephthalate glycol (PET).
scenario but demonstrate another behaior. This is een
applicable to simple liuids such as ethanol small mole-
cules. If a ery pure ethanol is stored in a bowl with no
corner and in a refrigerator without ibration, it can be
cooled to below freeing temperature without freeing.
ence there exists a temperature range below the melting
point called the supercooled region in which the sub-
stance remains liuid. If the cooling process is continued,
a temperature range will be reached at which the super-
cooled liuid transforms into a glassy state called the glass
transition temperature Tg. In this solidlie form, the sub-
stance has ery different properties than the crystalline
state. lassy material is an amorphous material, which
does not hae a long-range order. The structure of material
in the glassy form is therefore more similar to a liuid than
to a crystalline structure. xcept for only a few examples,
solid polymeric materials mainly exist in such an amor-
phous state. This is primarily related to the fact that the
polymer’s long chain is entangled with other chains. ence
it is usually difcult for the polymer chains to orientate and
build an ordered crystalline structure.
It has to be noted that simple polymers may actually
show crystalliation if the cooling rate is low enough so
that the polymer chains are allowed to nd their minimum
state of energy i.e., their euilibrium. oweer, for many
polymers with entangled chains, moements of polymer
chains are hindered too much, maing it physically impos-
sible to reach the crystalline state. The usual state of
polymers is, conseuently, solidlie with an amorphous
structure. eertheless, the polymer chains retain their
tendency to orient and to achiee an euilibrium state. This
tendency is the source of the specic behaior of amor-
phous polymers, which is plastic and elastic-lie, and
might alter between these characteristics throughout time.
55 60 65 70 75 80 85 90 95 100 105 110
Temperature (°C)
These aspects explain why the glass transition tempera-
ture plays an important role in dening a polymer’s proper-
ties, though it must be mentioned that the glass transition
temperature is an ill-dened transition. The latter means
that different measurement techniues may lead to differ-
ent Tg alues. ifferential scanning calorimetry  is a
widely accepted techniue for determination of the Tg
alue. ig. . shows results of  measurements for
T-. sually the middle of this range i.e., 5° for
T- is taen as the determined Tg alue.
rom an application-oriented iew, any thermoforming
must occur aboe the Tg temperature. The exemplied
 cure further indicates that, if T- is heated aboe
6°, its mechanical properties will change drastically.
ore specically, around a temperature of 6°, T-
will start to get softer and deform easier. Intraorally, this
temperature is usually not exceeded for a sufciently long
time, so T- stays mechanically stable during dental
applications.
Physical and Chemical Aging
of Aligner Polymers
In the fabrication process, aligners go through thermo-
forming. uring subseuent clinical application, they are in
contact with salia, food, drins, among other chemicals.
onseuently, as the orthodontist reuires a reliable appli-
ance, sufcient material stability is needed under arying
conditions. The stability of the aligner is measured by its
aging i.e., the change of its properties oer time. olymer
aging has seeral sources. ith respect to intraoral applica-
tion of polymers, two aspects of aging should be considered
in particular: physical and chemical aging.5 6

PHYSICAL AGING OF POLYMERS
hysical aging of polymers principally occurs, as men-
tioned earlier, in an amorphous i.e., noneuilibrium
form. ery system with the noneuilibrium state tends to
decrease its energy to thus approach its euilibrium state.
If enough mobility is obtained, the chains may rearrange
themseles to their lowest energy state, which might be
compared to crystalliation. This in turn will lead to a
decrease of the specic olume, a decrease of the enthalpy,
an increase of the hardness and brittleness, and changes
to other properties.5 This effect particularly changes the
mechanical properties of the polymer. ccordingly, physi-
cal aging can be dened as the relaxation of a polymer
toward a more stable energy state. If the usage of a poly-
mer occurs far below its Tg temperature, the polymer
chains will not hae enough inetic energy to moe and
rearrange. ence, by choosing an aligner with a Tg alue
much higher than the intraoral temperature, physical
aging might be largely aoided. It is important to note in
this context that a polymer’s Tg alue may also change
due to enironmental inuences.
hysical aging of polymers can be inuenced by expo-
sure to water and many other inds of molecules in the
intraoral medium. s mentioned, the specic olume of
an amorphous polymer is high in comparison to a crystal-
line polymer. This means there exists a lot of free olume
in the amorphous polymer below the Tg temperature.
onseuently, for prolonged exposure of such a polymer
to water, water molecules could diffuse into the material
alongside other molecules. The latter is one of the reasons
for discoloration of aligners. It is important to note that
the absorption of these molecules may also change the
properties of the polymer.  typical change is called the
plasticiing effect.6 To explain further, consider using
spaghetti as an example. roided that a bowl contains
spaghetti without sauce, the noodles cannot moe as eas-
ily because they stic together. oweer, by adding a sauce
to the bowl, the spaghetti noodles separate, which enables
them to slip along each other. In polymers, the plasticiing
effect follows almost the same logic: the small, embedded
molecules are placed between the polymer chains to in-
crease the mobility of the chains. The plasticiing effect
will reduce the glass transition, and therefore the polymer
will be more affected by physical aging.
rom a clinical perspectie, physical aging can affect an
aligner in two ways. Initially, the polymer will become softer
due to the plasticiing effect. s a result, force magnitudes
applied to the indiidual teeth are reduced. In the long run,
howeer, due to the effect of classical physical aging, aligner
polymers become harder which will increase the applied
forces and more brittle increasing the ris of breaage.
CHEMICAL AGING OF POLYMERS
s introduced, aligners may also suffer from chemical ag-
ing, which is the result of a chemical interaction between a
polymer and its medium. t present, none of the aailable
aligner materials is inert, which means that these materials
do react with certain chemicals included in salia, drin, or
food. hemical aging can affect a polymer ia different
mechanisms. or example, water molecules can brea the
3 • Clear Aligners: Material Structures and Properties 33
polymer chains and shorten them hydrolysis, or a similar
reaction can occur due to the interaction between the oxy-
gen and polymer oxidation.  polymer suffering from
chemical aging is more liely to deelop cracs and induce
notch effects.
ote, too, the time dependency of the mechanical prop-
erties of an aligner might be related to creep which will be
explained in the next chapter. reep is different from aging
phenomenon. It occurs due to application of mechanical
stress to the material, whereas aging is the result of a
polymer’s noneuilibrium state or medium, which occurs
without any external stress application. Both phenomena
are similar to each other, but they are related to uite differ-
ent mechanisms and should therefore not be confused.
Conclusions and Outlook
The two aligner materials mainly used i.e., T and
T- hae a distinct chemical structure leading to differ-
ent responses to thermoforming, exposure to the intraoral
milieu, and mechanical stress. ence it is of great impor-
tance not to generalie the characteristics determined for
one aligner material een one brand. ethodologic con-
ditions for material tests must be as realistic as possible.
or example, the mechanical properties of aligner materi-
als differ greatly before and after thermoforming. Thus a
realistic test should include the thermoformed material
specimen or aligners. urthermore, stress measurements
should be performed in a simulated intraoral medium.
lso, the production process the method of molding,
cooling, etc. affects polymer structure, which in turn
might alter the performance of aligner materials. To
obtain alid comparisons between tested materials and to
achiee reliable treatment results, test procedures and
clinical application protocols should be standardied. nly
then will the full potential of clear aligners be reealed.
ligner manufacturers or dental suppliers should inform
users i.e., orthodontists about any changes in the chem-
ical composition and production process. eertheless, it
is often rather difcult to obtain such information.
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 4 Inuence of Intraoral Factors
on Optical and Mechanical
Aligner Material Properties
FAYEZ ELKHOLY, SILVA SCHMIDT, MASOUD AMIRKHANI,
and BERND G. LAPATKI
Introduction
he triad of success of orthodontic therapy comprises pa-
tient compliance, biomechanical nowledge, and, for the
therapy with aligners, sufcient understanding of the ther-
moplastic material used. hapter  addressed the basic
chemical and mechanical properties of commonly used
aligner materials. his chapter will focus on the inuence
of different intraoral factors on the mechanical and optical
properties of aligner materials.
o achieve an efcient orthodontic tooth movement,
single aligners are usually worn for a period of  to  days
and approimately  hours per day. uring their period
of use, aligners are subjected to a prolonged eposure to
different factors that are inuencing their properties. hey
can be subdivided into two main categories. n the one
hand, there are factors inducing optical material changes,
either in the form of discoloration or increased opacity
such effects are related to the presence of salivary
enymes, plaue, and food and beverage coloring.- n the
other hand, there are factors affecting the mechanical
properties of aligners, including the periodic loading and
unloading of the material during its clinical handling,
combined with uneven local stress and strain distribution.
t must be noted, too, that ecessive occlusal forces e.g.,
during involuntary clenching or grinding and intraoral
temperature uctuations may inuence an aligner’s prop-
erties., As this appliance, however, is to be removed
during food or liuid intae and worn for only a relatively
short period, the clinical relevance of the latter two factors
may not be overemphasied.
he following sections will discuss the mechanisms of
how intraoral factors influence optical and mechanical
aligner properties and describe the clinical implications.
articular attention will be given to describing the
material-specific characteristics of the two aligner mate-
rials mainly used i.e., thermoplastic polyurethane 
and polyethylene terephthalate glycol -.  is
used, for instance, in the nvisalign system Align ech-
nology, anta lara, A, nited tates or  Aligner
weden  artina, ue arrare, adova, taly, whereas
- is used in the lear Aligner system uran, cheu
ental mbH, serlohn, ermany and the ssi system
ssi A1, entsply aintree ssi, arasota, , nited
tates.
Water Absorption
Aligners are constantly subjected to saliva, which con-
sists of 99% water. Hence it is crucial to understand the
mechanism and effects of water absorption as well as the
inuence of water absorption on the mechanical material
properties. As stated in hapter , amorphous polymers
such as  and - possess relatively low molecular
density, which provides free volume for water intae. A
previous study comparing these two materials showed
that  shows higher water absorption characteried by
a weight increase of .% after a -wee water storage
than - showing only a .% increase.9 esides this
weight effect, penetration of thermoplastic materials by
water molecules also leads to modication of their
internal structure. As eplained in hapter , this will
result in plasticiation because lins between polymer
chains are weaened or even destroyed, which reduces
the internal cohesion and increases the molecular mobil-
ity. he resulting loss of elasticity might eplain the
appearance of internal cracs observed in aligners after
clinical usage. t is interesting to note in this contet that
own studies on - material characteristics using
three-point bending of thermoformed rectangular speci-
mens revealed that the sole water storage without sub-
jecting the material to any mechanical loads has only a
minor impact on the mechanical material characteristics
ig. .. n contrast, if - is subjected to both water
and a continuous mechanical load, the effect on the
mechanical properties is much more pronounced, as indi-
cated by the reduction of the bending forces of up to %
see ig. ..
rincipally, water absorption could also induce dimen-
sional changes of the aligners, nown as hygroscopic
epansion. n theory, this factor—besides other factors
such as the initial play between the aligner and the setup
model-—might affect the t of the aligners and, con-
seuently, might also induce an alteration of the forces
applied to the individual teeth.9  A previous study on
water adsorption of thermoplastic materials, however,
did not nd signicant and plausible correlations be-
tween the rate of water absorption and the amount of
hygroscopic epansion.9 or instance,  showed a
lower hygroscopic epansion, although it showed the
highest water absorption rates.
35
36 Principles and Biomechanics of Aligner Treatment

Bending forces for PETG specimens

8
7
6

Force (N)
5
4
3
2
1


Dry (unloaded) 24 h loaded under dry conditions

24 h immersed in water (unloaded) 24 h loaded + immersed in water
Fig. 4.1 Bending forces depending on the (dry or wet) storage conditions and the unloaded or loaded condition.
Note 0.75mm polyethylene terephthalate glycol (PET-G) specimens were inestigated in a threepoint ending set
ting with a span length of  mm at a deection of 0. mm. The specimens were either only thermoformed and then
underwent only one short deection with simultaneous force stored for  hours in water without loading loaded
continuously for  hours without water immersion or loaded continuously for  hours with water immersion. The
error ars represent the standard deiation for the different measurements.

Optical Changes integuments, or the accumulation of plaue on the aligner

ne of the main reasons for the popularity of aligners with
patients lies in the invisibility or better the transparency
of this appliance.- hese characteristics should be main-
tained throughout the treatment period because a discol-
ored or opaue aligner ig. . might jeopardie the
patient’s motivation and compliance.
Aligner discoloration is primarily related to supercial
absorption or penetration of pigmentations in food and bev-
erages. offee i.e., the highest chromogenic agent, blac
tea, and red wine play a prominent role.   t is noticeable
in this contet that the rate and etent of discoloration is
material-specic. t seems that -based aligners might
ehibit faster discoloration rates than - aligners. A pos-
sible eplanation for this difference is the higher water ab-
sorption capability of  facilitating the accumulation of
the pigments.9 n addition, the higher surface roughness of
 might also facilitate the adhesion of pigments on the
polymer lm’s surface.
Aligners might also lose translucency by the develop-
ment of internal microcracs, formation of calcic
surface.-,9 bviously, the two latter changes do not have
a signicant impact on the treatment success due to the
short application period of each single aligner of maimally
 wees. oreover, the loss of translucency can be mini-
mied by maintaining good aligner hygiene through regu-
lar brushing with neutral soap and the use of denture-
cleaning effervescent tablets containing sodium bicarbonate
or sodium sulfate.
Short-Term Mechanical Loading
of Aligner Materials
SINGLE SHORT-TERM LOADINGS
or viscoelastic materials, it is nown that during very short
loading periods the elastic component dominates. his thesis
was also conrmed by unpublished investigation of -
specimens by our group, consisting of two short loading-
measuring cycles with a duration of only ca. . second each
and a -minute brea in between. he comparison of the

A B
Fig. 4.2 nisalign aligners. (A) Prior to rst intraoral application. (B) After a wee wearing period.
 4 • nuence of ntraoral actors on ptical and echanical Aligner aterial Properties 37

Force measured at short-term deflection

OCCLUSAL FORCES
8
n addition to the specic loading of aligners related to
7 repeated intraoral seating and removal, aligners are also
potentially eposed to relatively high mechanical loads
6 occurring during occlusal contacting. uch bite forces are
5 particularly relevant in patients showing clenching or
Force (N)

grinding where they may reach force values up to  

4 per single molar.
Although  possesses higher abrasion resistance than
3
-, available studies indicate that both materials
2 showed delamination and abrasion as well as an increased
icers hardness, particularly in the posterior region of
1 the dental arch.,,,9,, he latter was observed after a
0
-wee wear period and was traced bac to the changes in
the crystalline structure of the polymer under cold wor.
First loading Second loading evertheless, the clinical impact of these changes appears
Fig. 4.3 orces measured for 0.75mm polyethylene terephthalate unproblematic for two reasons irst, those teeth mainly
glycol (PT) specimens in a threepoint ending setup with a span affected by the altered material behavior i.e., the buccal
length of  mm. The central support was deected y 0. mm. Two teeth are moved to a minor etent during aligner therapy
short loadingmeasuring cycles with 0.second duration separated y second, the wearing period of an aligner ranging between
a minute recoery rea were performed.
 and  wees seems too short for the mechanical destruc-
tion of an aligner by contact forces.

forces obtained by the rst and second measurements did not

show a signicant difference ig. ..
MULTIPLE SHORT-TERM LOADING CYCLES
uring clinical application, aligners are removed multiple
times for food and liuid intae as well as during the regu-
lar oral hygiene procedures. o simulate or eemplify such
scenarios, our group conducted an in vitro study, includ-
ing cyclic loading of .-mm-thic  specimens
using a three-point bending setup. ach of the  cycles
consisted of a -minute loading interval, followed by a
nearly unloaded interval of  minutes during which the
deection was reduced to a level at which the remaining
force was just above   to maintain contact between the
force-measuring device and the specimen. As revealed by
ig. ., the - specimen showed a continuous stress
relaation behavior during the -minute loading periods
with a force reduction of ca. % average over the  load-
ing-unloading cycles. t was also observed that during the
-minute uasi unloaded period, a slight average in-
crease of the deection forces by ca. .% occurred. uch
force increase indicates a slight recovery of the - ma-
terial see ig. .. n some studies, such recovery is
described as “relaation” the latter epression, however,
should not be mistaen for “stress relaation,” which
describes a completely opposite phenomenon.
t is noteworthy that a similar material behavior was
found in another in vitro study in which --aligners
were repeatedly removed from a test model. his pre-
vious study observed a clear decrease of aligner force
delivery in the course of the  aligner seating-removal
procedures. oreover, the force reduction showed a
nearly linear relation with the freuency of the cycles,
with force values dropping down to % of the initial
forces after  cycles ig. .. urther wor is re-
uired to systematically eamine this aspect for other
materials than -.
Long-Term Loading
Aligner materials such as  and - show a visco-
elastic behavior. Hence they show both elastic and viscous
characteristics when undergoing loading, resulting in a
time-dependent deformation. uring very short loading
periods, the elastic component dominates. he time-
dependent viscous component, in contrast, reveals primar-
ily during prolonged loading. he viscoelastic behavior
can be mathematically described as standard linear solid
models ig. .. uch models consist of springs and
dashpots representing the elastic and viscous material
components, respectively.
perimental description of the mechanical behavior of
a viscoelastic material is possible by two variables creep or
stress relaation. t is important to clarify the difference
between these two parameters ig. .. reep describes
the phenomenon of increasing mechanical strain over time
in case of a constantly applied stress or force, respectively.
ince the mechanical load stress is maintained at a con-
stant level, creep eperiments induce a continuous defor-
mation strain see ig. .A until a maimum strain is
reached. tress relaation, in contrast, describes the grad-
ual stress decrease over time under a constant strain and
deformation, respectively see ig. .. As a result, the
force level drops continually until a certain euilibrium
state is reached at a reduced stress level. 
o ensure a better understanding of the viscoelastic prop-
erties of polymers, it is important to consider the specic test
method applied. reep is usually eamined either by tensile
measurements or by instrumental indentation tests.  
ensile measurements are usually performed by loading the
specimens at a certain force level, which is then maintained
for a certain period. he rate of elongation of the specimen
describes the creep rate of the tested material. nstrumental
indentation is more common and usually uantitatively
evaluated by calculating the percentage difference between
38 Principles and Biomechanics of Aligner Treatment

Short-term repeated loading

7
B
6

Force (N)
4

C
0
0 60 120 180
A Time (min)

6.75 0.5

x
y
Force (N)

Force (N)

6.25 0
0 10 20 35 45 55 65
B Time (min) C Time (min)
Fig. 4.4 (A) orces measured during multiple 5minute loading and 5minute loading cycles for a 0.5mm polyeth
ylene terephthalate glycol (PT) specimen in a threepoint ending setup with a span length of  mm and a deec
tion of 0. mm. (B) nlargement of a data segment (see top of A) showing the gradual force decrease during the
5minute loading time. () nlargement of a data segment (see bottom of A) showing the slight force increase during
the 0minute minimal load time at the corresponding deections.

Change in the mean force for different aligner removal frequencies

18
16
14
Mean force in (n)

12
10
8
6
4
2
0
0 10 20 30 40 50
Removal frequency (x times)
Fig. 4.5 Aerage force reduction reported for polyethylene terephthalate glycol (PT) aligners in the course of
50 aligner seatingremoal procedures ased on the data pulished y ai et al. 0 The error ars indicate the
standard deiation.
 4 • nuence of ntraoral actors on ptical and echanical Aligner aterial Properties 3

A B
Fig. 4.6 chematic modeling of iscoelastic material ehaior using a standard linear solid model. (A) awell
representation of a standard linear solid model. (B) elin representation of a standard linear solid model. uch
models comine springs and dashpots in a certain arrangement to descrie the oerall ehaior of a system under
different loading conditions. prings represent the elastic component of a iscoelastic material whereas dashpots
represent the iscous component.0 ue to comination of such elements an applied stress aries with the time
dependent change of the strain.

Creep Stress relaxation

Strain

Strain
Stress-strain

Stress-strain

Stress

Stress

A Time B Time
Fig. 4.7 Two fundamentally different eperiments and parameters respectiely descriing the timedependent
ehaior of a iscoelastic aligner material. (A) The creep phenomenon is osered if the load (and stress leel
respectiely) is ept constant oer time. (B) The stress relaation ehaior is characteried y loading the material
under constant strain and deection respectiely.

the initial and nal indentation depth during the constant
force application period. Hence it is determined how deep
the material has been penetrated over the designated
period. tress relaation, on the other hand, can be tested
either by three-point bending or in tensile eperimental
setups.,9 A common feature of both setups is the constant
deection strain of the specimen for a dened period dur-
ing which the time-dependency of the stress is registered.
he difference between the initial and residual values over
time denes the stress relaation rate.
Aligner materials with lower creep resistance tend to a
faster strain deformation under constant mechanical
stress. hen transferred to the clinical situation, such be-
havior would reduce the mechanical load applied to the
teeth because the relative discrepancy between the actual
tooth position and its position in the aligner would
diminish. A previous study investigated the creep behavior
of the different thermoplastic raw lms used in the nvis-
align Align echnology, anta lara, A, A, lear
Aligner cheu ental mbH, serlohn, ermany, and
ssi A1 entsply aintree ssi, arasota, , A
systems by means of indentation creep eperiments. he
indentation creep behavior was characteried by the
percentage increase of the indentation depth within an
interval of  minutes in with the specimens were subjected
to a constant indentation force., esults of this study
revealed more pronounced creep for modied , which
is the material of nvisalign aligners .% compared to
4 Principles and Biomechanics of Aligner Treatment

the corresponding percentage for - .%. Another Stress relaxation for Duran® PET-G
study observed that the creep of  was even more pro- specimens over a 7-day period
nounced after aging, with an increased indentation depth 100%
of %.
revious research determining the stress relaation 80%

Nomralized stress
behavior of commercial aligner materials revealed that

relaxation (%)
most materials show a relatively high stress relaation 60%
rate in the rst  hours of loading, followed by a nearly
steady plateau.  he stated stress decay, however, 40%
showed a material-dependent pattern with the highest
stress relaation for - with % of the initial stress 20%
values, followed by the stress relaation of  with
.%. After the -hour loading period, a similar ma- 0%
0 2 3 4 5 6 7
terial-dependent pattern was observed with residual
Time (days)
stresses of .% and % of the initial values for the
 and the - materials, respectively. imilar Fig. 4.8 Normalied stress relaation for polyethylene terephthalate
stress relaation patterns were found by our group inves- glycol (PET-G) materials loaded for  wee in a threepoint ending
setup with a constant deection of the specimen leading to a constant
tigating - specimens lear Aligner, cheu ental strain.
mbH, serlohn, ermany during a -wee constant
deection period with water immersion of the specimens.
ur results also indicated relatively rapid stress rela- viscous behavior that can be uantied, for instance, by
ation during the rst day, followed by a slower stress re- stress relaation eperiments. t is important to note that
duction. At the end of the longer -wee loading period, both the amount and the rate of deformation of thermo-
stress values approimated a residual stress value of only plastic materials depend on the loading time scheme and
% of the initial stress ig. .. the stress magnitude, and both are affected by collateral
factors such as the temperature and material-specic water
absorption properties. Another important characteristic of
Clinical Loading atterns of thermoplastic aligner materials is observed in cases where
Aligner Materials the load is removed. nder this condition, thermoplastic
materials may show a certain rebound effect. bviously
As mentioned, aligner materials possess elastic elements, such a phenomenon might be of practical importance as
which are of utmost importance for maintaining a certain during clinical therapy, aligners are usually removed peri-
force level on the teeth. f their load-deection behavior odically e.g., for food intae.
would be purely elastic, and the strain would be ept within o investigate this characteristic, recent research in our
the elastic range, then the force and moment components lab aimed at the eamination of the inuence of repeated
applied to the teeth would be directly proportional to the -hour loading-hour unloading cycles on the force
discrepancy between the actual tooth position and the pro- application of - aligner materials over a total period
grammed tooth position in the aligner. urthermore, the of  wee. An eample of a measurement curve is pre-
stiffness of the aligner material would describe the slope of sented in ig. .9. imilar to the eperiments with constant
this interrelation. As pointed out earlier, in case the load is strain, the results indicated a relatively high force decay in
maintained for a longer time, these materials also show a the rst few hours to a level less than % of the initial

Stress relaxation of PET-G

100%

80%
Force decay (%)

60%
Unloading interval

40%
Loading interval

20%

0%
1 2 3 4  6 
Measurement time (days)
Fig. 4. ecay of the forces measured after the loading and unloading periods during the wee oseration time.
 4 • nuence of ntraoral actors on ptical and echanical Aligner aterial Properties
force indicating a clear stress relaation. After the -hour
periods without loading, only slight force increases were
observed. ven though after the second and following load-
ing periods stress relaation could be observed, the latter
was much less pronounced than that occurring in the rst
loading period. ased on these ndings, we concluded that
the stress relaation behavior of -, which is related to
repeated loading and unloading intervals with similar
lengths as those typically occurring during clinical ther-
apy, tends to stabilie at a level between % and % of
the initial stress.
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palatal translation. J Orofac Orthop. -.
. lholy , chmidt , äger , et al. orces and moments applied dur-
ing derotation of a maillary central incisor with thinner aligners
41
an in-vitro study. Am J Orthod Dentofacial Orthop. 
-.
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- aligners during mesial and distal derotation of a mandibular
canine an in vitro study. J Orofac Orthop. -.
. hang , ai , ing , et al. reparation and characteriation of
thermoplastic materials for invisible orthodontics. Dent Mater J.
9-99.
. eremiah H, ister , ewton . ocial perceptions of adults
wearing orthodontic appliances a cross-sectional study.
Eur J Orthod. -.
. osvall , ields H, iuchovsi , et al. Attractiveness, accept-
ability, and value of orthodontic appliances. Am J Orthod Dentofacial
Orthop. 9, e- discussion -.
. halish , ooper-aa , vgi , et al. Adult patients’ adjustability
to orthodontic appliances. art  a comparison between abial,
ingual, and nvisalign™. Eur J Orthod. -.
. chott , ö . olor fading of the blue compliance indicator
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9. racco A, aoli A, avoni , et al. hort-term chemical and physi-
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. ai A, ei , Abusama , et al. ffects of time and clear aligner
removal freuency on the force delivered by different polyethylene
terephthalate glycol-modied materials determined with thin-lm
pressure sensors. Am J Orthod Dentofacial Orthop. 99-.
. Hattori , atoh , unieda , et al. ite forces and their resultants
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9-.
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. i , en , ang , et al. hanges in force associated with the
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. radley , ese , liades , et al. o the mechanical and chemical
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. ondo’ , aini , erroni , et al. echanical properties of
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 5 Theoretical and Practical
Considerations in Planning an
Orthodontic Treatment with
Clear Aligners
TOMMASO CASTROFLORIO, GABRIELE ROSSINI, and SIMONE PARRINI
Introduction
After the Stone Age, the Iron Age, and the Bronze Age, are
we switching to the Polymer Age? This question is legitimate
when examining the increase of plastic materials produc
tion during the last halfcentury
In the last decades, plastics hae permeated industrial
technology Plastic materials hae replaced many materials
used in the past, and they hae made possile industrial and
medical applications that would not hae een possile
with older technologies The ey to the widespread dissemi
nation of these materials is their incredile ersatility
urthermore, we are liing in the personalized medicine
era Personalized medicine represents the natural eolution
of health care hen medicine is informed solely y clinical
practice guidelines, the patient is not treated as an indiid
ual ut as a memer of a group Personalized or precision
medicine characterizes unique iologic characteristics of
the indiidual to tailor diagnostics and therapeutics to a
specic patient Personalized medicine uses additional in
formation aout the indiidual deried from nowing the
patient as a person
rthodontists hae always een educated in collecting
and analyzing patients’ indiidual characteristics to per
form a diagnosis and dene a personalized treatment plan
In this iew, orthodontics will e the pioneer in guiding
dentistry into the personalized medicine process hat is
still missing is the integration of iologic marers into the
diagnostic process and treatment planning, ut researchers
are going to ll the gap
In the last century, orthodontics was mostly a matter of
metals and predened prescriptions In the last decades, the
introduction of clear aligners moed the attention toward
thermoplastic materials and their possile applications and
personalized prescriptions In clear aligner therapy AT,
eery aligner is uilt for a specic stage of orthodontic tooth
moement T of a specic patient Aligners are com
fortale, less isile, and more aesthetically pleasant com
pared with uccal xed appliances they can e remoed for
eating and oral hygiene procedures, reducing the occur
rence of emergencies espite those adantages maing
clear aligner increasingly requested y patients in our
eautyconscious society, there was always a great deate
42
inoling efcacy and efciency of this appliance in con
trolling T or instance, questions hae een raised re
garding the extent to which aligners can control extrusion,
rotation, odily moement, and torque
As stated y Proft in , effectieness, efciency, and
predictaility are the three things orthodontists need to
now aout the treatment they are proiding A recent
reiew stated that AT can control complex moements
as maxillary molars odily distalization and extraction
spaces close and that the uccolingual inclination of inci
sors is well controlled in mild to moderate malocclusions
urthermore, in a recent research paper, rünheid et al
analyzed the differences etween predicted and achieed
tooth positions and found statistically signicant differ
ences for all teeth except maxillary lateral incisors, ca
nines, and rst premolars In general, anterior teeth were
positioned more occlusally than predicted, rotation of
rounded teeth was incomplete, and moement of posterior
teeth in all dimensions was not fully achieed oweer,
except for excessie posttreatment of uccal crown torque
of maxillary second molars, these differences were not
large enough to e clinically releant
Therefore, with respect to what was possile a few years
ago when the recommendation was to treat only simple
malocclusions with aligners, the growing ase of common
nowledge regarding the control of T made it possile to
use this technique een in more complex cases with good
results when compared to conentional xed orthodontics
Those results were made possile thans to orthodontists
who started to consider the irtual setup not only to isual
ize moing teeth ut as an instrument to design the proper
iomechanics, starting to transfer wellnown concepts in
this eld
As stated y Burstone during a JCO interiew
The nice thing about scientic biomechanics is that it is not de-
pendent on any given appliance or technique. No matter what
appliance you use, it allows you to use it better with more pre-
dictable results. Today, we have much too much commercialism
in orthodontics a healthy dose o science in understanding ap-
pliances and how they wor is a good antidote. t is interesting
to note that many o the new appliances that are suggested are
nothing more than reinventions o old appliances.
 5 • Theoretical and Practical Considerations in Planning an Orthodontic Treatment with Clear Aligners
Theoretical and Practical
Considerations in CAT
Based on these assumptions and on clinical and laoratory
research, the iomechanics of clear aligners could e de
scried as a sequence of crown tipping and root uprighting
The rst part of moement occurs in the occlusal part of the
tooth ecause the aligner enelopes the entire tooth crown,
while the interactions etween aligner and attachments de
termine root moement Therefore, when designing a irtual
treatment plan, we must always rememer which is the inter
action surface etween the aligner and the tooth, which is the
effect of the force application at the crown leel, and which is
the anchorage unit required to aoid undesired moements
The analysis of a irtual treatment plan using dedicated
software should e ased on the following steps
 Analysis of the nal position
 Analysis of the moements occurring at each stage for
each tooth
ANALYSIS OF THE FINAL POSITION
 
According to Sarer et al it may e inappropriate to
place eeryone in the same esthetic framewor and een
more prolematic to attempt this ased solely on hard tis
sue relationships since the soft tissues often fail to respond
predictaly to hard tissue changes eertheless, it is ac
cepted that esthetic considerations are paramount in plan
ning appropriate treatment ut that rigid rules cannot e
applied to this process In iew of our inaility to apply rules
dening optimal esthetics, the use of scientic methods to
plan the most esthetic treatment may therefore e compli
cated eertheless, it is clear that laypeople can identify
arious factors affecting smile esthetics Thus clinicians can
expect their patients to e more attentie to some dental
esthetic factors than they are to others
A recent reiew was conducted to dene the minimum
leel of esthetic harmony that can e approed as pleasur
ale y an external oserer The indications proided in
ig  represent the threshold of acceptance of smile es
thetics proided y laypeople that should e considered
when analyzing the nal position of front teeth
Fig  Thresholds of acceptance of smile esthetics from laypeople point of view.
43
egarding the nal position of upper maxillary molars,
it is recommendale to refer to the position indicated y
icetts in  in which the line connecting the distouc
cal and the mesiolingual cusps of the upper rst molar is
passing through the cusp of the opposite canine at the
end of treatment This nal position is ased on precise
anatomic landmars and can preent misunderstandings
etween the prescriing clinician and the technician trans
ferring the information in the irtual treatment plan
urthermore, when dening the nal position, the clini
cian should always consider the uccal and the frontal
limits of the arches, considering one and periodontal sup
port and the cephalometric information Those indications
are ery important to aoid excessie expansion andor
proclination moements that can result in seere periodontal
iatrogenic effects 
ANALYSIS OF THE MOVEMENTS OCCURRING
AT EACH STAGE FOR EACH TOOTH
The analysis of moements occurring in eery stage should
consider three different aspects
 Aligner auxiliaries
 Anchorage management and moement sequentialization
 T staging
Aligner Auxiliarie
Since the introduction of orthodontic aligners in early
s, seeral auxiliaries hae een adopted from manufac
turing companies and from clinicians to preent anchorage
loss and maximize treatment efciency
The most commonly adopted auxiliaries could e classi
ed as follows
n Attachments and pressure areas
n Intraoral elastics
n Interproximal enamel reduction IP
n Temporary anchorage deices TAs
Attachments and Pressure Areas.
sing aligners without attachments is something lie or
thodontics ut not orthodontics Attachments are useful to
guide teeth in a determined direction ut are also useful in
proiding anchorage control depending on the type of
44 Principles and Biomechanics of Aligner Treatment

planned orthodontic moement The use of attachments is

crucial to achiee effectie treatments aera et al and
arino et al demonstrated the importance of using at
tachments to improe the root control of distalizing molars
in class II treatments In an in itro study, Simon et al dem
onstrated that load transfer from aligners to teeth without
the use of attachment is possile only to a limited extent
Attachments are diided into two categories
 onentional attachments rectangular, eeled, or
ellipsoid
 ptimized attachments
onentional attachments igs , , and  can
e positioned y the clinician on eery tooth compatily
with tooth dimension and can e oriented in any direction
ectangular attachments are usually placed to increase Fig 4 Rectangular attachments on posterior teeth in Align Technology
ClinCheck software.
anchorage in posterior teeth or to reinforce the retention of
the aligner
ptimized attachments ig  are positioned y tech
nicians, and the orthodontist is not ale to modify their
position, dimension, and orientation This ind of attach
ment was introduced to generate a dedicated couple of
force during rotations, especially in canines and premolars
The “play” of aligners on teeth and attachments is an
other ey factor in producing desired outcomes, which is
strictly related to attachment application An in itro study
y asy et al demonstrated that attachment shape affects
retention ectangular attachments are more retentie

Fig  Optimied and conventional attachments in Align Technology

ClinCheck software.

than ellipsoid ones Two in itro studies demonstrated that

Fig 2 Rectangular attachments on posterior teeth in CA Digital
software.
Fig 3 Rectangular attachments on anterior teeth in CA Digital
software.
aligners produced y different companies Inisalign, Align
Technology, San osé, A, SA A lear Aligner, Scheu
ental, Iserlohn, ermany  Aligner, Sweden  ar
tina, ue arrare, Italy showed excellent tting on teeth
and attachments,  aligners seem to hae the est
alues in terms of tting on attachments the alues range
from  to  mm The Inisalign tting ranges from  to
 mm The measured alues for A lear Aligner analy
sis range from  to  mm asy et al demonstrated that
edgeless aligners generated signicantly lower forces than
those with a wider edge The increased force might e due
to the enhanced stiffness caused y material shape onse
quently, the enhanced stiffness may reduce the tting of the
aligner on the attachments This could e the reason why
A aligners showed the worst results in terms of tting
oweer, despite the statistical signicance, measured dif
ferences might not e clinically releant Therefore the play
of aligners on teeth and attachments is minimal, resulting
in a precise transfer of the mechanical properties of the
thermoplastic material to teeth
rom a iomechanical point of iew, only a few studies in
existing literature hae analyzed the interaction etween
aligners and attachments An efcient method for studying
aligner mechanics is the nite element method  Ap
plications of  on aligner studies will e presented in the
next parts of this chapter xcept for the ooi et al study,
reported  results will refer to the initial instance of
 5 • Theoretical and Practical Considerations in Planning an Orthodontic Treatment with Clear Aligners
aligner wearing thus these results should e considered in
terms of initial force systems and displacements, not taing
into account such precise measurements of the amount of
moement expressed y the aligner on teeth
sing , omez et al inestigated a theoretical mm
displacement of an isolated upper canine with and without a
composite attachment The attachment considered for this
analysis was inspired y the “optimized attachments” adopted
y Align Technology to increase root control during distaliza
tion The authors osered uncontrolled distal crown tipping
without the attachment and a displacement similar to odily
moement with the attachment Thus the authors highlighted
the difculty to otain a controlled moement in AT using
only aligners and suggested the use of composite attachments
to increase root control
The iomechanical explanation of attachments useful
ness in controlling tooth moement could e related to the
role of races in xed orthodontics hile in xed appliance
orthodontics the moment is deeloped in the racet itself
y the engagement of the wire, in AT it is deeloped y the
interaction of aligner and auxiliaries The aligner with
out attachments tends to moe away from the teeth in its
gingial edge In such eentuality, all force is concentrated
only in the occlusal part, and no couple of force could e
generated hen recurring to attachments, the interaction
etween the displacement applied to the aligner and the at
tachment generates the adequate forces and moments to
otain a more controlled moement
ooi et al in  pulished a paper that demonstrated
these concepts using  to compare upper incisor dia
stema closure without attachments and with optimized
ones As reported y authors, the initial displacement cor
responded to uncontrolled crown tipping for oth the simu
lations howeer, after hundreds of iterations that simu
lated the one remodeling process, the simulation without
attachments resulted in uncontrolled tipping, while odily
moement was osered in the simulation with optimized
attachments
egarding pressure areas, the ind of moements in which
they are adopted depends on the aligner manufacturer su
ally, pressure areas are adopted to improe efciency in
crown tipping, rotations, and root torquing Barone et al in
their  study from  reported that pressure areas are
Fig  nitial tooth displacement of second molar distaliation with class  elastics applied directly on upper canine
(sagittal view).
4
the most effectie auxiliaries in lower incisors tipping, een
more than rectangular attachments
A study y astro§orio et al regarding control of root
moement demonstrated the efcacy of pressure areas to
improe this type of moement The force couple gener
ated y an aligner torquing a tooth consists of a force near
the gingial margin and a resulting force produced y
moement of the tooth against the opposite inner surface of
the appliance near the incisal edge Since the gingial
edge of the aligner is elastic, it is difcult to control the
forces applied in this region without an altered geometry
Intraoral Elastics.
egarding intraoral elastics, three main ariales could
in§uence the right choice for the planned treatment
 orcelength
 Application point
 Application surface
igs  through  refer to upper molar distalization,
which will e thoroughly analyzed in the following chap
ters, and present the effects of elastics on teeth and aligners
while changing application point The same elastic  in,
 oz was applied so that the forcelength ariale would
not affect the analyzed ones The difference in aligner defor
mation and teeth initial displacement during second upper
molar distalization could e osered
In the preiously cited study, omez et al osered an
intrusie effect on the canine due to an unexpected defor
mation of the aligner during distalization A loose tting
etween aligner and tooth would achiee inadequate con
tact with the gingial optimized attachment and thus fail to
produce a correct couple of force This eentuality could e
aoided y class II elastic that assists during distalization
moement proiding anchorage with the sagittal compo
nent of elastic force and preenting intrusion thans to its
ertical component
Interproximal Reduction.
Since rst descried y Ballard in , IP has een a
procedure dedicated to mildtomoderate crowning cases
oweer, in the last years, the digitalization of treatment
planning increased the adoption of this technique to otain
4 Principles and Biomechanics of Aligner Treatment

Fig  nitial tooth displacement of second molar distaliation with Fig  nitial tooth displacement of second molar distaliation with
class  elastics applied directly on upper canine (occlusal view) class  elastics applied on aligner at upper canine level (occlusal view).

Fig  nitial tooth displacement of second molar distaliation with class  elastics applied on aligner at upper
canine level (sagittal view).

Fig  nitial aligner displacement of second molar distaliation with class  elastics applied directly on upper
canine.

space during orthodontic treatment, also improing its ac
curacy and precision uring AT digital planning, the IP
amount is calculated ased on digitally performed dental
index scores Bolton index, ittle index, space analysis, etc,
and the timing of IP is programmed to otain the est in
terproximal surface access and to aoid premature tooth
surface collisions As demonstrated y seeral authors, IP
is a safe procedure for tooth health, which does not increase
the riss of interproximal caities and tooth demineraliza
tion, egarding IP maximum amount, in  Sarig
et al analyzed  extracted intact anterior and posterior
teeth from oth maxilla and mandile The authors re
ported that the existing guidelines of mm max IP for
each interproximal space could e conrmed for anterior
region, while in the posterior region it could e increased
to  mm
 5 • Theoretical and Practical Considerations in Planning an Orthodontic Treatment with Clear Aligners
Fig  nitial aligner displacement of second molar distaliation with class  elastics applied on aligner at upper
canine level.
Temporary Anchorage Devices.
Aligner treatment with TAs is thoroughly analyzed in
hapter 
Anrage Manageen an Meen
Seuenialiain
Anchorage management represents the ey for a successful
orthodontic treatment In xed orthodontic treatment,
auxiliaries such as laceacs, tieacs, and elastics are ad
opted to reinforce anchorage when needed, principally dur
ing the woring phase of treatment espite the widespread
use of aligner orthodontics, no iomechanical studies are
present to date to erify the efciency of aligners alone in
maintaining anchorage
In aligner orthodontics, as well as in conentional ortho
dontics, anchorage loss could result in inefcacy of pro
grammed moements or in undesired moements of anchor
age unit A paper y ortona et al reported the effects of
anchorage loss on a contralateral premolar during rotation
of a lower premolar without attachments
Anchorage in aligner orthodontics depends on two ey
factors sequentialization of moements and aligner defor
mation
Sequentialization in aligner orthodontics is intended as
the order in which teeth are moed during the treatment
oement sequentialization allows a proper anchorage
control, reducing the ris of undesired displacements ul
tiple moements at the same time should e aoided unless
we are referring to small amounts of moement on seeral
teeth, as in such cases when we are aligning and leeling
the arches in mild class I malocclusions, for example ul
tiple complex moements as well as lingual root torque
moement associated with rotation and extrusion or intru
sion moements of an upper incisor, as an example, should
e always aoided In cases when multiple moements hae
een planned on a specic tooth, the est option is to split
moements ased on their complexity Therefore, torque
moement should e performed a second time, at least once
rotational and tipping moements hae een completed
ore detailed sequentialization protocols will e analyzed
in dedicated chapters Among sequentialization resides
also the concept of “differential forces and moments” This
concept is the result of the iomechanical design of a
force system, which y the way of its application can
distriute the reciprocal forces and moments oer signi
cantly different root areas with the oectie of eliciting a
4
differential response Seeral studies demonstrated the
efciency of this method in presering anchorage and ante
rior torque during space closure after a premolar extrac
tion, In aligner orthodontics, these concepts hae een
introduced y Align Technology with the socalled  pro
tocol for rst premolar extraction ifferential moments
are produced with a comination of optimized attachments
and aligner actiation howeer, no detailed force systems
are pulicly aailale and to date no trials hae een con
ducted to measure the outcomes of this clinical protocol
Aligner deformation is intended as the response of the
whole aligner to the stress caused y tting it on teeth
uring aligner wearing, a push and pull force system in
oles not only the teeth for which moements are planned
ut also adacent teeth and the aligner itself ig 
shows the tooth displacement during upper second molar
distalization in an efcient force conguration note that
while  mm of moement was planned for tooth ,
 mm is efciently applied on the tooth, while the other
amount results in mesial displacement of the aligner An
other example of anchorage loss due to aligner deforma
tion is reported in ig , in which mesial displacement
of molars is highlighted during sequential distalization of
premolars irst and second molars, in this simulation,
were set as an anchorage unit oweer, without proper
auxiliaries to increase anchorage and manage aligner de
formation, een a good moement sequentialization could
e not adequate
OTM Saging
In aligner orthodontics, staging is intended as the amount
of programmed moement per tooth in each aligner Stag
ing amount is determined y each aligner company ased
on internal research, thus default staging settings may differ
etween one another egarding scientic literature, ei
denceased data aout staging are ery poor Simon et al,
in their  in itro study, tested different amounts of stag
ing for premolar rotation The accuracy for this moement
was haled when a rotation greater than  degrees per
aligner was planned , degrees  12  .
degrees  12  The importance of staging for
tooth rotation could e highlighted in the paper y ortona
et al A simulation, including an ideal dental arch with
element  rotated  degrees mesially, was tested with dif
ferent staging and attachment congurations for premolar
distal rotation Staging of  and  degrees of rotation per
4 Principles and Biomechanics of Aligner Treatment
Fig 2 nitial tooth displacement of second molar distaliation with class  elastics applied on aligner at rst
premolar level. nitial displacement amount is shown in the attached legend.
Fig 3 nitial tooth displacement of rst molar and second premolar distaliation without class  elastics. The mesial
shift of posterior teeth is clinically relevant.
aligner was compared and the difference in periodontal liga
ment P pressure on tooth  etween the different
amount of staging with rectangular attachments from
tooth  to  was reported Planned rotation of  de
grees produced  mmg of pressure on periodontal liga
ment, while  degrees of planned rotation otained pressure
of  mmg Thus the model with attachments from
 to  and  degrees of actiation was the most reli
ale and efcient conguration for lower premolar rotation
idenceased data regarding staging for other moe
ments may e deried from in itro and clinical studies, ut
there is a lac of dedicated trials Tale  reports the sug
gested amount of moement per aligner ased on scientic
literature and clinical expertise of the authors
Table 5.1 uggested Amount of ovement per Aligner
Rotation   ,.°
ntrusiontrusion . mm
inear ovement    . mm
Root Torue   
°
Biologic Considerations in Aligner
Orthodontics
As stated at the eginning of this chapter, personalized
medicine applied to orthodontics is ased not only on dedi
cated mechanics ut also on the nowledge of each pa
tient’s iology
The application of an orthodontic force produces a tissue
reaction resulting from the perturation generated y the
orthodontic appliance and the modeling and remodeling of
the aleolar one uncio et al suggested that teeth
moed with aligners did not undergo the typical stages of
moement, as descried y rishnan and aidoitch, e
cause of the intermittent forces applied y the aligners
oweer, light, continuous forces seem to e perceied as
intermittent forces y the periodontium due to its iscoelas
tic nature, and orthodontic intermittent forces can produce
T with less cell damage in the periodontium astro§o
rio et al, in analyzing the iologic response to the applica
tion of aligners distalizing a maxillary molar in a single
tooth moement design study, showed that the force deli
ery produces an increased concentration of one modeling
 5 • Theoretical and Practical Considerations in Planning an Orthodontic Treatment with Clear Aligners
and remodeling mediators at oth pressure sites interleu
in  eta Ib, receptor actiator of nuclear factor
appaB ligand A and tension sites transforming
growth factor eta Tb, osteopontin P In other
words, aligners seem to e capale of inducing the same
iologic responses descried for other appliances at least in
the ery early stages of orthodontic treatment
Patient Compliance
espite all iologic and iomechanical aspects, the success
of an orthodontic treatment strictly depends on patient
compliance ompliance with remoale orthodontic align
ers is fundamental for the efciency and success of AT in
the short and long term
A  systematic reiew uilt on preious primary re
search conrmed suoptimal leels of compliance with a
ariety of remoale orthodontic aduncts, alluding to ac
tual wear durations of  hours per day less than recom
mended
The in§uence of treatment progress appeared to e
signicant to motiate compliance, although it could e
argued that facial and occlusal improement is most
liely in more compliant patients anyway otwithstand
ing this, demonstrale change was frequently reported as
a facilitator of appliance wear As such, the importance
of encouragement and positie reinforcement y clini
cians and family memers in encouraging appliance wear
is clear
Pilot studies in the eld hae demonstrated that nown
monitoring increases patient compliance, The use of an
app was effectie in increasing patient compliance in a
xedappliance population ustomized reminders may
help to promote enhanced leels of compliance with align
ers thans to teleorthodontics Teleorthodontics is a road
term that encompasses remote proision of orthodontic
care, adice, or treatment through the medium of informa
tion technology Teleorthodontics platforms using articial
intelligence to remotely monitor patient adherence to the
prescried wearing time are aailale eg, ental onitor
ing, Paris, rance and hae een demonstrated to e effec
tie in enhancing patient compliance
CAT Fundamentals Recap
onsidering all the premises, aligner orthodontics is a ma
ture orthodontic technique requiring orthodontists to man
age it properly Some limitations in the appliance system
remain, ut they in no way suggest unsatisfactory treat
ment results iagnosis and treatment plans still remain
the responsiility of clinicians and cannot yet e oercome
y articial intelligence
It is clear that treatment progress is not as easy and
predictale as dictated y computer animation Therefore,
giing priority to technology instead of orthodontics is
dangerous The nowledge of iomechanics is crucial to
properly manage clear aligner therapy oreoer, lie
any other orthodontic technique, auxiliaries are manda
tory to perform an efcient and predictale orthodontic
treatment
4
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y remoale thermoplastic aligners incisor torque, premolar dero
tation, and molar distalization m J Orthod entoacial Orthop

 Barone S, Paoli A, azionale A, et al omputational design and
engineering of polymeric orthodontic aligners nt J Numer ethod
iomed ng e
 ennessy , arey T, AlAwadhi A A randomized clinical trial
comparing mandiular incisor proclination produced y xed laial
appliances and clear aligners ngle Orthod 
 ayes , Sarer , acoson A The quantication of soft tissue
cericomental changes after mandiular adancement surgery m J
Orthod entoacial Orthop 
 Sarer , Acerman  rthodontics aout face the reemergence
of the esthetic paradigm m J Orthod entoacial Orthop

 loresir , Sila , Barriga I, et al ay person’s perception of
smile aesthetics in dental and facial iews J Orthod 

 Parrini S, ossini , astro§orio T, et al aypeople’s perceptions of
frontal smile esthetics a systematic reiew m J Orthod entoacial
Orthop 
 camara r A, Brudon  Orthodontic and Orthopedic Treatment in
the ied entition Ann Aror eedham Press 
 auddin S, g P, Biswas S, et al Iatrogenic damage to the peri
odontium caused y orthodontic treatment procedures an oeriew
Open ent J 
 ati AS, urquim , onsolaro A ingial recession its causes and
types, and the importance of orthodontic treatment ental ress J
Orthod 
 aera S, astro§orio T, arino , et al axillary molar distalization
with aligners in adult patients a multicenter retrospectie study
rog Orthod  dois
 arino , astro§orio T, aher S, et al ffectieness of composite
attachments in controlling uppermolar moement with aligners
J Clin Orthod 
 asy , asy A, Asatrian , et al ffects of ariale attachment
shapes and aligner material on aligner retention ngle Orthod
 doi
 antoani , astro§orio , ossini , et al Scanning electron
microscopy ealuation of aligner t on teeth ngle Orthod
 doi
 antoani , astro§orio , ossini , et al Scanning electron micros
copy analysis of aligner tting on anchorage attachments J Oroac
Orthop  dois
 Principles and Biomechanics of Aligner Treatment
 ooi , Arai A, awamura , et al ffects of attachment of plastic
aligner in closing of diastema of maxillary dentition y nite element
method J ealthc ng 
 omez P, Peña , artínez , et al Initial force systems during
odily tooth moement with plastic aligners and composite attach
ments a threedimensional nite element analysis ngle Orthod

 Breznia  The clear plastic appliance a iomechanical point of
iew ngle Orthod 
 astro§orio T, arino , azzaro A, et al pperincisor root control
with Inisalign appliances J Clin Orthod 
 rünheid T, aalaas S, amdan , et al ffect of clear aligner ther
apy on the uccolingual inclination of mandiular canines and the
intercanine distance ngle Orthod 
 Ballard  Asymmetry in tooth size, a factor in the etiology, diagnosis,
and treatment of malocclusion ngle Orthod 
 oretsi , hatzigianni A, Sidiropoulou S namel roughness and in
cidence of caries after interproximal enamel reduction a systematic
reiew Orthod Cranioac es 
 achrisson B, yøygaard , oarac  ental health assessed
more than  years after interproximal enamel reduction of man
diular anterior teeth m J Orthod entoacial Orthop

 Sarig , ardimon A, Sussan , et al Pattern of maxillary and
mandiular proximal enamel thicness at the contact area of the
permanent dentition from rst molar to rst molar m J Orthod
entoacial Orthop 
 ortona A, ossini , Parrini S, et al lear aligner orthodontic ther
apy of rotated mandiular conical teeth a nite element study ngle
Orthod  Sumitted for pulication minor reision
 anda  r aindra anda on orthodontic mechanics Interiew
y oert  eim J Clin Orthod 
 uhlerg A, Priee  Testing force systems and iomechanics—
measured tooth moements from differential moment closing loops
ngle Orthod 
 aoody A, Posada , trea A, et al A prospectie comparatie
study etween differential moments and miniscrews in anchorage
control ur J Orthod 
 ie P Treating imaxillary protrusion and crowding with
the inisalign  rst premolar extraction solution and inisalign
aligners O Trends Orthod 
 iu , u  orce changes associated with different intrusion
strategies for deepite correction y clear aligners ngle Orthod

 rishnan , aidoitch  iological echanisms o Tooth ovement
nd ed ooen,  ileyBlacwell 
 uncio , aganzini A, Shelton , et al Inisalign and traditional
orthodontic treatment postretention outcomes compared using the
American Board of rthodontics oectie grading system ngle
Orthod 
 attaneo P, alstra , elsen B Strains in periodontal ligament
and aleolar one associated with orthodontic tooth moement
analyzed y nite element rthod raniofac es 

 astro§orio T, amerro , aiglia P, et al Biochemical marers
of one metaolism during early orthodontic tooth moement with
aligners ngle Orthod 
 Aloghrai , Salazar , Pandis , et al ompliance with remo
ale orthodontic appliances and aduncts a systematic reiew and
metaanalysis m J Orthod entoacial Orthop 
 luni A, olonio Salazar B, Sharma P, et al nderstanding
factors in§uencing compliance with remoale functional appli
ances a qualitatie study m J Orthod entoacial Orthop

 Pauls A, ienemper , Panayotidis A, et al ffects of wear time
recording on the patient’s compliance ngle Orthod

 Arreghini A, Trigila S, omardo , et al ectie assessment of
compliance with intra and extraoral remoale appliances ngle
Orthod 
 i , u , Tang , et al ffect of interention using a messaging
app on compliance and duration of treatment in orthodontic patients
Clin Oral nvestig 
 ansa I, Semaan S, aid , et al emote monitoring and “tele
orthodontics” concept, scope and applications emin Orthod

 6 Class I Malocclusion
MARIO GRECO
Introduction
Class I malocclusions represent one of the most common
conditions in the daily clinical practice and one of the most
elective conditions to be treated with aligners, since the
primary patients’ concern is often represented by crowded
anterior teeth, especially in the mandibular arch.1
Working with clear aligners challenges the paradigm on
which we, as orthodontists, based the traditional ed me
chanics approach. Working with aligners means that we
need to plan everything in advance and not on a monthly
basis, dening nal teeth position from the beginning and
spending more time in treatment plan design and staging
than at the chairside.
Diagnostic Reference
When dealing with class I malocclusion, the rst step to con
sider is the denition of the biologic limits of the arches. We
should identify anterior, frontal, and vertical limits. ll the
limits represent both a morphologic limit torue posterior
and anterior strictly connected to bone and teeth pattern of
movement and an esthetic indication to dene eactly the
ideal teeth positioning in relationship to lips and face.
ore specically, during treatment plan in class I maloc
clusion a very schematic approach could be focused on the
observation and respect of the following key points
n sthetic key points face midline, smile arc, intraarch
symmetry
n cclusal key points olton analysis, overet, incisors
inclination
ubstantially the esthetic indicators represent the limits in
which teeth need to be moved on the horiontal plane arch
symmetry, face midline and on the vertical plane smile arc
the occlusal indicators are useful to dene the proper veret
needed to ensure anterior clearance and avoiding premature
anterior contacts causing posterior open bite in relation
ship to dental sie and anterior limit of dentition.
Treatment Plan
he development of proper treatment plan in class I maloc
clusion starts from the denition of correct staging of
movement to create a reliable digital setup and to reach a
predictable result with high superimposition between the
real and the digital settings. he ideal approach in terms of
treatment staging should be based on curve of pee level
ing, incisor control, arch development, rotation control,
attachment choice, and interproimal reduction I.
CURVE OF SPEE LEVELING
o avoid anterior premature contacts, to create the proper
cuspids and molars intercuspations, and to allow lower
incisor leveling and correct anterior relationship related
to guidance function, attening of the curve of pee is
reuired. oreover, the assessment of the amount of lev
eling will give information about the space needed for
curve attening.
INCISOR CONTROL
aving in mind the precise angular inclination of lower
incisors according to the cephalometric references and us
ing the superimposition tool andor the movement table
tool, together with the grid tool of digital setup software, is
possible to determine the amount of proclination or retro
clination reuired to properly locate the lower incisors on
the sagittal plane.
ARCH DEVELOPMENT
In terms of treatment approach, epansion represents a
very common solution to treat crowding and transverse
discrepancy. uccal tipping movement is more predictable
than bodily movement when planning arch epansion with
aligners. his should be kept in mind when dening the
buccolingual inclination of canine premolars and molars
respecting the periodontal condition.
ROTATION CONTROL
otation of small teeth or round teeth such as premolars
could be considered a difcult movement to achieve be
cause of the reduced tooth surface on which the force can
be applied. Comple rotations should be managed by rst
creating the mesial and distal spaces reuired to rotate
teeth and then choosing the proper attachment.
ATTACHMENT CHOICE
ttachments represent a useful tool to increase the surface
on which orthodontic forces could be applied ig. .1. ee
previous chapters for more details.
INTERPROXIMAL REDUCTION
ne common procedure in aligner techniue is represented
by the I, which ideally should be limited to . mm per in
terproimal point to avoid too wide enamel reduction. he
management of I is fundamental not only for ing crowd
ing problems and nding more space but also to control the
51
52 Principles and Biomechanics of Aligner Treatment

A B
Fig. 6.1 Biomechanical design of conventional attachments for extrusion (A) and distal rotation (B)

incisor inclination i.e., creating space with I could rep I could represent a reliable solution to recreate ideal
resent a reliable system to upright upper or lower incisors, alignment, but some options during the digital setup plan
to compensate olton discrepancy by reducing teeth ecess, ning need to be controlled to avoid collateral effects, as
and to create symmetric dimension between left and right follows
sides.1 n void ecessive proclination of lower incisors by means
of using the superimposition tool and the grid tool of the
software and by favoring transverse epansion and con
Class I Conditions seuently a more uprighted position of lower incisors
ig. ..
Class I malocclusions can be divided into different catego n lace the lower premolars to a buccal crown torue net
ries following the principal condition that affects speci
to ero to recreate space without changing the interca
cally one or more dimensions of the space transverse or
nine width when on the occlusal picture of lower aw, it
vertical or which creates a determinate discrepancy. or
is possible to observe the labial surface of premolars,
this reason they will be discussed separately.
torue correction could be achieved ig. ..
n Combine class III elastics to create the proper  1. mm
DENTOALVEOLAR DISCREPANCY and to favor the correction of crowding also in absence of
real class III relationship ig. ..
he most common condition is represented by crowding in n Create upper and lower aw ideal shape to avoid black
the upper or lower arch or both. he clear aligner treatment
triangles and buccal facial corridors ig. ..
C of crowding is highly predictable when approached n lan specic attachments see Chapter  ig. ..
with the proper staging such as epansion, small proclina
tion, reduced I, and torue correction. ormally, being
able to avoid etractions means that treatment options
available are related to epansion  mm per uadrant and
I . mm maimum per interproimal space. he se
verity of crowding, particularly in the lower aw, signi
cantly affects the possibility of avoiding etraction treat
ment. Conditions in which it is reasonable to treat without
etraction are as follows
n ight crowding, with normal amount of I .1
. mm
n ild to moderate crowding, with combination of epan
sion without changing intercanine width and maimum
rate of . mm of I per interproimal space
n oderately severe crowding, combining the .mm I
per interproimal space with torue correction of lower
premolars to create a positive torue up to a maimum
of  degrees of buccal torue inclination
his means that when the crowding is lower than  mm
Fig. 6.2 ClinCheck tools to check incisor inclination.
per uadrant, the possibility to combine epansion and

A B
C D
E
Fig. 6.3 Pretreatment records oung adult patient ith severe croding and negative premolar torue. (A intraoral
pictures)
TOOTH SIZE DISCREPANCY
he olton analysis is important because it allows the im
mediate visualiation of the interarch and intraarch dis
crepancies. hese discrepancies can affect the nal overet.
ot considering the olton analysis in our treatment plans
could lead to several unfavorable outcomes anterior prema
ture contacts with posterior open bite without reaching a
proper class I intercuspation on both sides, ecessive procli
nation of incisors, and uncorrected closure of upper diaste
mas. herefore, the tooth sie discrepancy analysis is crucial
when designing orthodontic treatment. thman and arra
dine recommended a threshold of mm discrepancy to be
6 • Class I Malocclusion 53
of clinical signicance for restorative intervention igs. .
and ..111
nother common condition of tooth sie discrepancy is
represented by dental anomalies in number bilateral or
monolateral agenesis and dental anomalies in shape mi
crodontia, pegshaped lateral incisors. In the case of a
monolateral agenesis in the anterior area missing upper
lateral incisor, the olton analysis can provide the precise
dimension of the contralateral incisor helping the clinician
in dening the right space that needs to be preserved for the
nal restoration. In case of pegshaped contralateral incisor
the olton analysis provides information regarding the
54 Principles and Biomechanics of Aligner Treatment

A B

C D

Fig. 6.4 Posttreatment records oung adult patient ith severe croding and negative premolar torue treated
ith torue correction and interproximal reduction. (A intraoral pictures)

A B

Fig. 6.5 (A) Pretreatment records oung adult patient ith narro up
per arch and smile lack corridors. (B) Posttreatment records oung
adult patient ith narro upper arch and smile lack corridors treated
ith upper expansion and loer torue correction. Fig. 6.6 oule conventional attachment in case of severe rotation.
 6 • Class I Malocclusion 55

A B

C D

Fig. 6. Pretreatment records tooth sie discrepanc A intraoral pictures.

B C

D E

Fig. 6. Posttreatment records toothsie discrepanc treated  space opening and interproximal reduction A igital
proect B intraoral pictures.
56 Principles and Biomechanics of Aligner Treatment
golden proportion between the anterior si teeth helping
the clinician in determining the right space to be preserved
for the nal restorations. In the case of bilateral agenesis in
which the treatment is designed to close the space of later
als with mesial movement of canines, premolars, and mo
lars, the tooth sie discrepancy values are fundamental to
reduce the dimension of canines that will become laterals
and to increase the dimension of premolars that will be
come canines.11
TRANSVERSE DISCREPANCY
ne of the most duple conditions to be treated with
aligners is represented by the transverse discrepancy the
term duplex refers to the different compleity in the treat
ment of anterior crossbite and posterior crossbite, since
anterior crossbite represents an elective condition to be
treated with aligners while the posterior relies its possibil
ity to be successful on the severity of posterior crossbite
and on the use of supporting auiliary devices cross
elastics ig. ..
he anterior crossbite central, lateral, or canine in bilat
eral or monolateral conguration is a perfect condition to be
approached with Invisalign aligners since the thickness of the
aligner itself avoids any need of bite turbos to create disclu
sion, a condition needed during traditional ed orthodontics.
or this reason, the treatment of one single element of anterior
crossbite could be predictably ed with a lite lite is the com
mercial name of Invisalign with reduced number of aligners.
or this reason is not light but lite. reatment if the rest of
A n
B tal control should be planned class II or III ig. .1.
Fig. 6. Cross (AB intraoral pictures) elastics to support posterior
expansion.
Fig. 6.1 Anterior contact during uccal movement for crossite
resolution.
malocclusion conditions permits this simplied approach.
he following should be done to increase predictable results
n uring treatment the buccal movement of laterals or
centrals will create an edgetoedge contact to overcome
this traumatic contact, it may be convenient to change
aligners more rapidly to reduce the time eposed to
trauma ig. .1.
n ogether with labial movement to  the crossbite, some
millimeters of etrusion should be planned to create
normal overbite.
n enerally, in case of anterior crossbite, the ape of the
element is located more buccal compared to the crown
for this reason, unparticular root movement is reuired
igs. .11 and .1.
he correction of posterior crossbite represents a vari
able, predictable correction with aligners according to the
severity of the crossbite one single element crossbite could
be easily managed only by the system, while for the correc
tion of severe maillary contraction with multiple elements
in crossbite the use of auiliaries is widely suggested. In
particular, these indications should be followed to create a
reliable correction
n In case of single element crossbite, more crown torue
should be planned instead of buccal epansion.
In case of multielement crossbite, buttons for crisscross
elastics should be planned to help the correction and sup
port the elastic modication of the aligners by using di
rect bonding on the teeth and cooperation with 1 hours
of elastics  o,  mm.
n o simplify the correction, some minimal I in the in
terproimal spaces could be helpful only to remove pos
sible initial interferences while starting the epansion.
n he use of bite ramps even in the absence of deep bite is
strongly suggested. It could simplify the posterior move
ment creating disclusion, favoring the buccal movement
and the vertical etrusion moment in combination with
crisscross elastics igs. .1 and .1.
n ccording to the malocclusion, further elastics for sagit
n In case of severe maillary contraction, a crown torue
inclination assessment should be done to understand the
amount of possible correction only with dental epansion.
 6 • Class I Malocclusion 5

A B

C D
Fig. 6.11 Pretreatment records of lateral incisor in anterior crossite. A intraoral pictures

A B

C D
Fig. 6.12 Posttreatment records ith complete correction of crossite in reduced numer of aligners. AB intraoral pictures
5 Principles and Biomechanics of Aligner Treatment

A B

C D

E
Fig. 6.13 Pretreatment records of severe posterior crossite ith maxillar contraction. A intraoral pictures

he predictable plan for posterior crossbite is basically
focused on epansion up to . mm per uadrant. If the
crown torue of lateral elements and the periodontal condi
tion could allow this kind of correction, the combined use
of bite ramps and crisscross elastics could predictably in
crease the outcome achievement.
MORPHOLOGIC DISCREPANCY
ess common conditions of class I malocclusions are repre
sented by those situations of teeth with morphologic anom
alies, such as single or multiple anterior agenesis and
microdontia conoid laterals, that affect the orthodontic
treatment and ideal outcome according to the therapeutic
choice.
ll morphologic discrepancies are strictly connected to
olton discrepancy, and for this reason the same approach
described later should be followed to achieve proper occlu
sal outcome and normal overet. oreover, an important
consideration should be done on the microesthetics and
macroesthetics when teeth show a different shape.
In the case of monolateral dental morphologic anomaly
conoid or agenesis, it becomes necessary to leave the
proper space to concentrate on the opposite normal shape
element dimension. he olton button could provide infor
mation about teeth sie, and on the ClinCheck it is possible
 6 • Class I Malocclusion 5

A B

C D

E F
Fig. 6.14 Posttreatment records after expansion 1 torue correction 1 interproximal reduction 1 ite ramps. A
intraoral pictures  igital setup shoing ite ramps for posterior disocclusion.

A B
Fig. 6.15 Class III elastics. A intraoral pictures B igital etup
6 Principles and Biomechanics of Aligner Treatment
to plan space opening mesial and distal to the conoid ele
ment to organie the nal restoration ig. .1. In case of
single agenesis, one further assessment should be done con
cerning the space between the roots. ince the nal restora
tion will be an implant, it is fundamental to measure the
space between the apees to realie if the outcome could
be achieved only with aligners or some auiliaries will be
needed. When the apical distance is around  mm, no other
special auiliaries will be needed, ust the space opening
between crowns, while when the distance is less than  mm,
some auiliaries lingual sectional or power arm could be
necessary to achieve the proper space for implant insertion
igs. .1 and .1.
In the case of agenesis of both lateral incisors, the choice
of space closure with total mesial movement of posterior
teeth or space opening for implant insertion has long been
discussed in the literature.11 ctually, in case of young
patients, the ideal solution seems to be the space closure
with reshaping of the canines both additive and subtrac
tive enamel plastic to simulate laterals combined with re
shaping of rst premolars simulating canines additive
enamel plastic. he advantages of approaching with
A B
C
Fig. 6.16 pace opening for Peg shaped restoration. A pretreatment B digital plan C post treatment
aligners are the possibility to have all the information
about sie of the teeth olton tool, balancing I on ca
nines and space opening on rst premolars to create ideal
anterior relationship between the si anterior teeth com
bined with leveling the anterior gingival margins to create
a harmonic smile igs. .1 and ..
PREPROSTHETIC NEED
he last common condition analyed of class I malocclu
sion is strongly related to those situations in which the
orthodontic treatment could be helpful in creating more
favorable conditions for prosthetic solution, thus gaining
space where it was missing for nal restoration. eing very
schematic, two conditions in adult patients with missing
teeth commonly reuire the orthodontic support to achieve
an ideal prosthetic solution, namely
1. ipping in the edentulous space
. vereruption in the edentulous space
he mesial tipping of molars, in particular the tipping of
second molars because of missing rst molar, represents a
1.0
1.0
 6 • Class I Malocclusion 61

A B

C D

Fig. 6.1 Pretreatment records of lateral incisor agenesis ith apical distance less than  mm. A intraoral pictures
 panoramic xra

freuent condition sometimes combined with distal tipping
of premolars.11 pproaching this problem with the align
ers is highly predictable because of the following
n he force to upright the second molar creates a reaction
force, which upright the premolars and this reciprocal force
work properly together in opening the space ig. .1.
n he amount of space can be decided in advance on the
software according to the dimension of the contralateral
element.
n o be more efcient, it is possible to ask to avoid pontics
in the edentulous area to leave the aligner to embrace
more surfaces of the molar to upright delivering more
homogeneous force.
n In the ClinCheck plan it is fundamental to combine distal
inclination of crown with distal movement to put the
center of rotation net to the ape.
or the same reason when one or more teeth are missing,
the problem could happen in another dimension of the
62 Principles and Biomechanics of Aligner Treatment

A B

C D

E
Fig. 6.1 Posttreatment records of monolateral lateral incisor agenesis ith Invisalign and xed sectional for root
control. A intraoral pictures

space affecting the vertical movement overeruption of
molars.
pproaching this problem with traditional orthodontics
means that an auiliary device for skeletal anchorage in the
bone will be strongly needed. he traditional biomechanics
to intrude molars are highly comple for anchorage
lack.11 he opportunity to solve the overeruption with
aligners simplies the treatment because the vertical force
of intrusion is applied to the teeth by means of labial, lin
gual, occlusal, and distal surface not only on side, and it
generates a reaction force that tends to etrude the ada
cent tooth blocked by the occlusion and the thickness of
aligners. his biomechanical system is more in balance
when compared to traditional, and if no other movements
in different planes are reuired, it can be accomplished in
reduced number of aligners igs. . and ..
 6 • Class I Malocclusion 63

A B

C D
Fig. 6.1 Pretreatment records of ilateral lateral incisors agenesis. A intraoral pictures

A B

C D
Fig. 6.2 Posttreatment records of ilateral lateral incisors agenesis treated  space closure and teeth reshaping.
A intraoral pictures
64 Principles and Biomechanics of Aligner Treatment

A B

Fig. 6.21 pace opening  distal tipping of molars. A pretreatment intraoral picture B posttreatment intraoral
picture ith implant inserted

A B

C
Fig. 6.22 Pretreatment records of overerupted upper second molar. AB intraoral pictures C panoramic xra

A B

Fig. 6.23 Posttreatment records of overerupted upper second molar treated  aligners onl. AB intraoral picture
C panoramic xra

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 7 Aligner Treatment in Class II
Malocclusion Patients
TOMMASO CASTROFLORIO, WADDAH SABOUNI, SERENA RAVERA,
and FRANCESCO GARINO
Introduction
Since the introduction of clear aligner treatment (CAT),
controversy has existed over whether moderate to difcult
orthodontic treatment can be routinely accomplished with
aligner techniue hen dealing with class  malocclu
sions, CAT offers different possible therapeutic options
 istaliation
 olar derotation
 lastic ump
 xtractions
 andibular advancement
 rthognathic surgery
MAXILLARY MOLAR DISTALIZATION
n some nonextraction cases, maxillary molar distaliation
is the method of choice to gain  to  mm of space in the
dental arch to obtain a class  relationship in both teens
and adults
The upper molars can be distalied by means of extraoral
or intraoral forces xtraoral traction with headgear has a
long history of use in class  treatment since it has been
designed to push distally the maxilla and the maxillary mo
lars, n recent years, several techniues have been devel
oped to reduce the dependence on patient compliance, such
as intraoral appliances with and without seletal anchor
age owever, even these devices can produce undesirable
tipping of the maxillary molars andor loss of anterior an
chorage during distaliation, To achieve a tooth bodily
movement implies that the applied force must pass through
the center of resistance of the tooth or a sophisticated
euivalent system of forces and moments needs to be ap
plied to the tooth crown A recent review of the existing
literature assessed the efcacy of aligners in aligning and
straightening the arches, with better results for mild to
moderate crowding when compared to the results obtained
with xed appliances ore recently, it was stated that the
overall available evidence regarding orthodontic tooth
movement (T) control during CAT increased signi
cantly, with three randomied controlled trials (CTs) at
grade A and an overall uality of evidence of moderate
high level, and that maxillary molar distaliation of
 mm and premolar extraction space closure ( mm) are
the most predictable and controlled movements with CAT
n , Simon et al stated that maxillary molar dis
taliation was the most predictable movement () to
66
perform with CAT The authors started to focus on the ey
role of a correct staging of the planned movement and of
the adoption of proper attachments during the whole dis
taliation phase Thus a highly signicant element of bias
in the  study by rae et al was the staging of
 mm per aligner instead of the  mm recommended
n , avera et al conrmed the results of Simon
et al and demonstrated that distaliation is efciently
achievable up to  mm on the rst and second maxillary
molars, with optimal vertical control of posterior teeth and
any loss of anchorage on the anterior teeth These results
were obtained through the combination of staging, vertical
rectangular attachments, and class  elastics (– o)
for anchorage reinforcement The use of attachments and
elastics was previously described by expert clinicians The
application of composite attachments could be useful to
improve the biomechanic efciency of aligner therapy ong
vertical attachments located on the buccal aspect of the
molars can create a sufcient moment to oppose the tipping
movement Thus long vertical attachments can provide
good tipping control while molars are moving and then can
increase posterior anchorage while retracting anterior
teeth
The need for a determined attachment combination
was conrmed in a  CT by arino et al, who ob
served signicant differences in the amount of distalia
tion when comparing a veattachment conguration
(second and rst molars, second and rst premolars, and
canine) with a threeattachment conguration (rst mo
lar, second and rst premolars), with the rst ones being
most efcient Controlling the tipping movement during
molar distaliation can be difcult because of the limited
alignertooth surface in the direction of force application
The absence of long rectangular attachments on the sec
ond molar resulted in a probable loss of anchorage during
the distaliation of the rst molar, with conseuent re
duced amount of distal movement of the second molar at
the end of the treatment and signicant tipping of the rst
molar urthermore, the absence of a proper anchorage
preparation in the distal portion reduced the possibility of
an adeuate control of the retracting anterior teeth As a
result, the central incisors showed an uncontrolled tip
ping movement in the group with a threeattachment
conguration
ecently ome et al demonstrated that when the
aligner segment was displaced distally without attach
ments, a clocwise moment and distal inclination were

produced on the upper canine The presence of composite
attachments helped counteract this inclination, producing
a countermoment that in turn favored a bodily movement
n another nite element analysis study, Comba et al
demonstrated that the use of attachments on tooth surface
counteracts the uncontrolled tipping during distaliation
through the generation of a countermoment that ends in
the root uprighting This moment is dependent from a com
plex force system and is generated by the active surfaces of
attachments hen analying a couple of attachments
located on the buccal surface of an upper canine, one
located at the distocervical portion and the other located
at the mesioincisal portion, compression areas were found
on the mesial face of the cervical attachments and on
the distal face of the incisal attachment These outcomes
validate ome ndings
The vertical pattern is an important point to consider
while planning molar distaliation The distal movement
measured in our study was associated with signicant in
trusion movements of the molars The thicness of the
aligners and the conseuent occlusal force exerted on them
might facilitate intrusion and explain the absence of any
change of anterior vertical dimension while distaliing
urthermore, ome et al reported a mared tendency of
“aring” of the buccal and palatal ans of the aligner seg
ment during distal displacement This nding is interesting
because it could suggest an intrusive effect on the tooth
The aligner therapy is a customied orthodontic treat
ment for both the patient and the orthodontist The pres
ence of composite attachments for the control of the
maxillary molars during the distaliation process is a
choice of the prescribing clinician for most of the avail
able systems in the maret
MAXILLARY MOLAR ROTATION
esiopalatal rotation of the upper rst molar is present in
about  of patients with angle class , division  maloc
clusion and in  of them as a whole  esiopalatal
rotation of upper rst molars often ends up in an intraarch
loss of space reuently, this crowding occurs in the pre
molar and canine segments, thus potentially preventing the
correct mesiodistal position of these teeth n this basis,
buccodistal rotation of maxillary molars can be considered
a useful procedure to partially improve class  dental rela
tionship olar rotation was indicated as one of the predict
able movements controlled by aligners
THE ELASTIC EFFECT
The elastic effect can be dened as class  correction using
interarch mechanics t is simulated on virtual setups by a
umplie shift of the occlusion from class  to class  to al
low easier visualiation of the anticipated treatment goal
ndividual tooth movements reuired to align teeth are set
up to proect the effect of this bite correction using buttons
and elastics
lastic wear is recommended from the start of treatment,
continuing until the desired anteroposterior correction has
been achieved
7 • Aligner Treatment in Class II Malocclusion Patients 67
The effect of elastics is simulated as a onestage antero
posterior movement at the end of treatment, which enables
verication of the nal arch coordination and occlusion
ewer aligners are reuired when simultaneous stag
ing is used along with use of elastics as compared with
distaliation owever, a preparation phase in which all
the possible interarch interferences are removed is re
uired in the virtual setup planning to create enough
room in which the class  elastics can promote their
effects
espite the large use of class  elastics in everyday prac
tice, little evidence is nown about their effects A recent
systematic review stated that the current literature sug
gests using light forces (average,  o) obtained with
a in diameter elastic and a rectangular  to
in stainless steel archwire n aligner orthodon
tics, the use of in diameter  o was recom
mended, on the basis of expert clinician experience
owever, as shown in Chapter , nite element analysis
has shown the need for stronger class  elastics in CAT
ecause class  elastics heavily rely on patient compliance,
fulltime usage is recommended t has been described as
an average period of  months for the correction of the
class  discrepancy with elastics only, and the correction is
usually obtained with predominant dentoalveolar effects
This is the average treatment time reuired to correct an
endtoend class  malocclusion according to existing lit
erature
EXTRACTIONS
lease refer to Chapter  for specics on extractions
MANDIBULAR ADVANCEMENT
lease refer to Chapter  for specifics on mandibular
advancement
ORTHOGNATHIC SURGERY
rthognathic surgery consists of surgical procedures
performed on the maxilla andor the mandible to correct
serious basal malocclusions and to harmonie the prole
t is benecial in adults since the most difcult cases
cannot be treated by orthopedic and orthodontic therapy
alone
lease refer to Chapter  for specics on orthognathic
surgery
The Clinical Protocol
istaliation is performed to correct average to moderate
class  malocclusions (, mm) by retracting the maxillary
teeth istaliation should be preferred in patients present
ing a class  malocclusion due to maxillary protrusion or in
adult patients undergoing compromise treatment
uring distaliation, it is essential to use class  elastics
or miniscrews to avoid loss of anchorage at the anterior
teeth,,
68 Principles and Biomechanics of Aligner Treatment
epending on the severity of the sagittal malocclusion,
we can use different clinical approaches
n or dental sagittal discrepancies where less than  mm
of distaliation are needed, we can safely perform aligner
driven seuential distaliation
n or dental discrepancies ranging between  and  mm,
depending on the clinical situation, we perform seuen
tial distaliation combined, or not, with stripping, molar
derotation, or an elastic effect
n f dental discrepancy exceeds  mm, we opt for either extrac
tion treatment or orthognathic surgery, once again depend
ing on the clinical situation and the patient’s decision
Maxillary Distalization Case Reports
CASE SUMMARY 1
A yearold female patient ased for an aesthetic orth
odontic treatment easy to manage considering her ob as a
maeup artist traveling across urope
Fig. 7.1 Case 1 initial clinical and radiographic records.
She presented a class , division  relationship, mild
crowding in the lower arch, and moderate crowding in the
upper arch The overet was increased to  mm The prole
analysis revealed protruded lip position (ig )
Considering the aesthetics reuest of the patient and
her refuse for surgical interventions or extractions, the
treatment plan was designed to obtain a nal molar
and canine class  relationship through a seuential dis
taliation of the maxillary teeth using nvisalign (Align
Technology nc, San osé, CA, SA) aligners, composite
attachments on all the distaliing teeth, and class 
elastics   (ig )
The patient was instructed to wear the aligners and the
class  elastics for at least  hours per day urthermore,
she used the Acceleent device for  minutes every day
of the orthodontic treatment Aligners were changed ev
ery  wees until the maxillary second molars were fully
distalied, then every  days until the rst molars were in
their nal position, and then every  days until the end of
treatment The ClinChec (Align Technology nc, San
osé, CA, SA) software revealed the need for  aligners
to obtain the prescribed results (distaliation planned for

Fig. 7.1, ’
 mm) with the prescribed seuence of stages, attach
ments, and class  elastics Thus the estimated treatment
time was approximately  months The patient chose to
use Acceleent, and the case was closed in  months
of treatment without further aligner with respect to the
prescribed (ig )
The clinical results were excellent and revealed nal
molar and canine class  relationships with functional
overbite and overet The prole of the lower third of the
7 • Aligner Treatment in Class II Malocclusion Patients 69
face was highly improved with respect to the beginning
(ig )
The superimposition of the cephalometric tracings re
vealed a maxillary molar distaliation of about  mm
without signicant tipping and an excellent control of the
buccolingual inclination of the incisors (ig )
The class  elastics were responsible for a mandibular
protraction of about  mm etention was provided by
ivera (Align Technology nc, San osé, CA, SA) retainers
7 Principles and Biomechanics of Aligner Treatment

Fig. 7. Case 1 frontal and sagittal views of initial ClinCheck.

Fig. 7. Case 1 nal clinical and radiographic records.

 7 • Aligner Treatment in Class II Malocclusion Patients 71

Fig. 7., ’

7 Principles and Biomechanics of Aligner Treatment

Fig. 7. Case 1 frontal and sagittal views of nal ClinCheck.

Fig. 7. Case 1 lateral ra comparison and cephalometric maillar superimposition efore and after therap.

CASE SUMMARY 
A yearold female patient ased for an aesthetic orth
odontic treatment easy to manage
She presented a class , division  relationship, moderate
crowding in the upper arch, and mild crowding in the lower
arch The overet was increased to  mm The prole analy
sis revealed an acceptable lip position (ig )
Considering the aesthetics reuest of the patient and her
refuse for orthognathic surgery, the treatment plan was
designed to obtain a nal molar and canine class  relation
ship by a seuential distaliation of the maxillary teeth
using nvisalign (Align Technology nc, San osé, CA, SA)
aligners, composite attachments on all the distaliing teeth,
and class  elastics The average distaliation movement
prescribed was  mm (ig )
The patient was instructed to wear the aligners and the
class  elastics for at least  hours per day Aligners
were changed every  wees until the maxillary second
molars were fully distalied, then every  days until the
rst molars were in their nal position, and then every
 days until the end of treatment The ClinChec (Align
Technology nc, San osé, CA, SA) software revealed
the need for  aligners to obtain the prescribed results
with the prescribed seuence of stages, attachments,
and class  elastics The estimated treatment time was
approximately  months
n an intermediate phase, rst outcomes of seuential
distaliation were clearly visible As shown in igs  and
, molars already distalied in a correct class  relation
ship were spaced apart from premolars
 7 • Aligner Treatment in Class II Malocclusion Patients 7

The clinical results were excellent and revealed nal molar
and canine class  relationships with correct overbite and overet
The prole of the lower third of the face was slightly improved
with respect to the beginning, since the aesthetic analysis and
cephalometric measurements showed acceptable values at the
beginning of the treatment already (igs  and )
The superimposition of the cephalometric tracings
revealed a maxillary molar distaliation of about
 mm without significant tipping and an excellent
control of the buccolingual inclination of the incisors
(ig )

Fig. 7.6 Case  initial clinical and radiographic records.

Continued
7 Principles and Biomechanics of Aligner Treatment

Fig. 7.6, ’

Fig. 7.7 Case  frontal and sagittal views of initial ClinCheck.

 7 • Aligner Treatment in Class II Malocclusion Patients 7

Fig. 7.8 Case  upper occlusal views at the eginning after molar distaliation and at the end of therap.

Fig. 7.9 Case  end of distaliation intraoral frontal occlusal and sagittal views.
76 Principles and Biomechanics of Aligner Treatment

Fig. 7.1 Case  nal clinical and radiographic records.

 7 • Aligner Treatment in Class II Malocclusion Patients 77

Fig. 7.1, ’

Fig. 7.11 Case  frontal and sagittal views of nal ClinCheck.

78 Principles and Biomechanics of Aligner Treatment

Fig. 7.1 Case  lateral ra comparison and cephalometric maillar superimposition efore and after therap.

CASE SUMMARY 
This yearold female patient has no previous orthodontic
history, a full mm left and rightside molar class  maxil
lary alveolar arch width deciency,  mm of maxillary
crowding, a mm overbite, and an mm overet Seletally
she presented a hypodivergent class  and a cervical verte
brae maturation (C) stage  sthetically her face was
harmonious in both frontal and lateral views (ig )
esidual growth was insufcient to consider orthopedic
treatment Conseuently, taing into account the aesthetics
reuest of the patient, the treatment plan was designed to
correct the class , achieving nal molar and canine class 
relationship by molar derotation, seuential distaliation,
and elastic ump using nvisalign (Align Technology nc,
San osé, CA, SA) aligners, composite attachments on all
the distaliing teeth, and class  elastics The average distal
iation movement prescribed was  mm
The patient was instructed to wear the aligners and the
class  elastics for at least  hours per day Aligners were
changed every  wees until the maxillary second molars
were fully distalied, then every  days until the rst
molars were in their nal position, and then every  days
till the end of treatment To obtain the prescribed results,
 aligners were needed (ig )
The clinical results were good and showed nal molar
and canine class  relationships with correct overbite and
overet The prole of the lower third of the face was
improved with respect to the initial records (ig )

Fig. 7.1 Case  initial clinical and radiographic records.

 7 • Aligner Treatment in Class II Malocclusion Patients 79

Fig. 7.1, ’

Continued
8 Principles and Biomechanics of Aligner Treatment

Fig. 7.1, ’

Fig. 7.1 Case  sagittal views of initial intermediate nal pre and postump ClinCheck.

Fig. 7.1 Case  nal clinical and radiographic records.

 7 • Aligner Treatment in Class II Malocclusion Patients 81

Fig. 7.1, ’

8 Principles and Biomechanics of Aligner Treatment
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for moderate to complex malocclusions J Dent Educ 
 anda S, Tosun S Correction of Anteroposterior Discrepancies anover
ar uintessence ublishing Co 
 rec , anson , ranco C, et al ntraoral distalier effects with
conventional and seletal anchorage a metaanalysis Am J Orthod
Dentofacial Orthop 
 ontana , Coani , Caprioglio A oncompliance maxillary
molar distaliing appliances an overview of the last decade Prog
Orthod 
 golf , eole A, pshaw S actors associated with orthodontic
patient compliance with intraoral elastic and headgear wear Am J
Orthod Dentofacial Orthop 
 uiy A, odrigues de Almeida , anson , et al Sagittal, vertical,
and transverse changes conseuent to maxillary molar distaliation
with the pendulum appliance Am J Orthod Dentofacial Orthop 

 ontana , Coani , Caprioglio A Soft tissue, seletal and dentoal
veolar changes following conventional anchorage molar distaliation
therapy in class  nongrowing subects a multicentric retrospective
study Prog Orthod 
 usy  nuence of force systems on archwirebracet combinations
Am J Orthod Dentofacial Orthop 
 ossini , arrini S, Castroorio T, et al fcacy of clear aligners in
controlling orthodontic tooth movement a systematic review Angle
Orthod 
 ossini , arrini S, eregibus A, et al Controlling orthodontic
tooth movement with clear aligners An updated systematic
review regarding efcacy and efciency J Aligner Orthod 

 Simon , eilig , Schware , et al orces and moments generated
by removable thermoplastic aligners incisor torue, premolar dero
tation, and molar distaliation Am J Orthod Dentofacial Orthop

 rae CT, corray S, olce C, et al rthodontic tooth movement
with clear aligners ISRN Dent 
 avera S, Castroorio T, arino , et al axillary molar distaliation
with aligners in adult patients a multicenter retrospective study
Prog Orthod 
 Simon , eilig , Schware , et al Treatment outcome and efcacy
of an aligner techniue—regarding incisor torue, premolar derota
tion and molar distaliation BMC Oral ealth 
 aher S Dr Sam Daher’s echniues for Class II Correction ith Inis
align and Elastics httpssamaonawscomlearninvisalign
docspxAACpdf
 auette  xtraction treatment with nvisalign n Tuncay , ed
he Inisalign Sstem ew alden uintessence ublishing Co

 arino , Castroorio T, aher S, et al ffectiveness of composite
attachments in controlling uppermolar movement with aligners
J Clin Orthod 
 ome , eña , artíne , et al nitial force systems during
bodily tooth movement with plastic aligners and composite attach
ments a threedimensional nite element analysis Angle Orthod

 Comba , arrini S, ossini , et al Threedimensional nite element
analysis of uppercanine distaliation with clear aligners, composite
attachments, and class  elastics J Clin Orthod 
 Solanoendoa , Sonnemberg , Solanoeina , et al ow effec
tive is the nvisalign® system in expansion movement with x’
aligners Clin Oral Inestig 
 anson , Sathler , ernandes T, et al Correction of class  mal
occlusion with class  elastics a systematic review Am J Orthod
Dentofacial Orthop 
 ohamed , asha S, AlThomali  axillary molar distaliation
with miniscrewsupported appliances in class  malocclusion a
systematic review Angle Orthod 
 amada , uroda S, eguchi T, et al istal movement of maxillary
molars using miniscrew anchorage in the buccal interradicular
region Angle Orthod 
 8 Aligners in Extraction
Cases
KENJI OJIMA, CHISATO DAN, and RAVINDRA NANDA
Introduction
The demand for inconspicuous and natural-feeling orth-
odontic appliances has been rising over time. The introduc-
tion of the Invisalign system marked a signicant step for-
ward in orthodontics in that it allowed for inconspicuous
orthodontic correction using appliances with a natural feel.
The original Invisalign system, however, came with serious
limitations: the control of root movement was not possible
and it was difcult to move large teeth over signicant dis-
tances.1-1 ecent advances in the uality of materials, the
use of attachments, and the introduction of a new force
system have epanded the range of applications of the
Invisalign system from mild crowding to more difcult
etraction cases.11-1
s is the case with all orthodontic procedures, one of the
greatest sources of dissatisfaction among adult patients
with aligner therapy is the long treatment time. This report
describes the treatment of a patient with severe anterior
crowding who was treated with Invisalign appliances after
the etraction1- of her three remaining premolars. er
lower left premolar had already been removed.  photobio-
modulation device was used to possibly accelerate tooth
movement.
Diagnosis and Treatment Plan
hen this -year-old female presented at our clinic, she
epressed a desire to correct her maillary anterior crowd-
ing and improve the aesthetic appearance of her smile.
hile the patient’s facial prole was straight, both lips were
slightly recessive with regard to the -line ig. .1. n in-
traoral eamination showed a class II molar relationship
with a -mm overet, a -mm overbite, and coincident mid-
lines. The arch-length discrepancy was 1 mm in the ma-
illa and 1 mm in the mandible. Infralabioversion was
noted for both upper canines and a marked buccal shift of
the upper left second molar ig. ..
ephalometric analysis indicated a skeletal class II rela-
tionship with a steep mandibular plane angle ig. .. The
upper central incisors were slightly inclined lingually and
the lower central incisors were inclined labially. The lateral
gap in the mandibular head conrmed by her panoramic
-ray did not impede mandibular function. There was evi-
dence of slight regression in the periodontal tissue around
the upper canines with no tooth mobility, the maimum
pocket depth was  mm.
ased on these observations, the patient was diagnosed
as a skeletal class II case with infralabioversion of the
maillary canines and a steep mandibular plane angle.
The treatment plan called for the retraction of both upper
and lower incisors: 1. mm of movement was reuired in
the mailla and 1. mm in the mandible. irst, the two
upper rst premolars and lower right second premolar
were etracted. er lower left second premolar had been
removed in her early teens. Therefore, to allow for mesial
movement, her upper left second molar and upper right
third molar were etracted, too. ecause the patient e-
pressed concern about the poor aesthetics of ed orth-
odontic appliances over a potentially long period of time,
the decision was made to implement the Invisalign system
in conunction with photobiomodulation rthoulse to
possibly speed up treatment.1-
linheck software was used to analye the location,
angle, and need for the recontouring of the canine in rela-
tion to the nal desired occlusion ig. .. deuate inci-
sor retraction in this class II malocclusion reuired the
-mm distal movement of the upper rst molars and -mm
mesial movement of the lower rst molars. ven after the
etractions, there was insufcient space to move the mail-
lary anterior teeth by premolar etraction alone. To create
more space, the overepansion of the dental arches was
reuired. Tooth movements were simulated on the lin-
heck software ig. ., the amount of epansion re-
uired in each arch was estimated, the positions were
planned, and the shapes of the reuired attachments were
decided.
Treatment Progress
Three third molars were removed ecept the upper left
third molar before treatment. fter the etraction of the
upper premolars and lower left rst premolar, aligner treat-
ment was initiated. e used all the maillary teeth from
rst molar to rst molar as anchorage for the distaliation
of the second molars. In the mandible, we used all the teeth
ecluding the canines and second premolars as anchorage
for the mesial movement of the canines. ince the root of
the lower right canine was angled outward, we moved the
tooth simply by tipping the lower left canine was moved
bodily along with its root. The distaliation of the upper
second molars was completed in 1 weeks and distal move-
ment of the upper rst molars was completed  weeks later.
The closure of the lower etraction space continued during
this period with mesial movement of the lower rst molars.
fter  months of treatment, retraction movement of the
upper canines was completed, with the incisors of the mid-
line corrected. t this point, we recalculated the retraction
83
84 Principles and Biomechanics of Aligner Treatment

A B

C D

E F

Fig. 8.1 (A) Smile appearance of the patient. (B) Frontal picture at rest. (C) Three-quarter picture at rest. (D) Three-quarter
smile appearance. () Prole smiling. (F) Prole at rest.
 8 • Aligners in traction Cases 85

Fig. 8.2 nitial intraoral pictures.

A B

Fig. 8.3 (A) nitial orthopantomograph. (B) nitial lateral -ra.

86 Principles and Biomechanics of Aligner Treatment

A B

C D

Fig. 8.4 ClinChec initial stage. (A) Frontal ie. (B) ight
ie. (C) eft ie. (D) pper arch ie. () oer arch
E ie.

A B

Fig. 8.5 Schematic representation of ertical orthodontic tooth moement design in the frontal plane (A). Amount
of ertical moements for upper canines and central incisors (B).

space for the maillary incisors by means of a panoramic
-ray. ince the mandibular etraction spaces were closed,
we could use all the teeth from second premolar to second
premolar, including the canines, as anchorage for the me-
sial movement of the lower rst molars.
The aligner margins were trimmed about  mm to
accommodate direct-bonded hooks on the upper rst ca-
nines. ingual buttons were bonded to the distobuccal
edges of the lower rst molars, and class II elastics . in,
 o were prescribed to be worn  hours per day. To pre-
vent the mesial tipping of the lower rst molars, vertical
rectangular attachments were added to their mesiobuccal
edges ig. ..
Improvement was seen in the anteroposterior relation-
ship after use of the class II elastics, and a class I relation-
ship was established in the buccal segments. The net phase
involved the retraction of the upper anterior teeth. fter
Fig. 8.6 Schematic representation of attachments and auiliaries required
in etraction cases.
A B
Fig. 8.7 (A) nitial smile esthetic analsis. (B) ClinChec simulation into the smile frame of the Digital Smile Design
softare.
8 • Aligners in traction Cases 87
 months of treatment, the rst linheck phase was n-
ished igs. . and ..
The distaliation of the upper rst molars was complete,
with space visible at the mesial edge of the upper left rst
molar. The movement of the lower second premolars and
canines had closed all the mandibular spaces.
The shapes and positions of the attachments were modi-
ed for the renement phase. The crown positions were
considered together with the root positions to decide the
optimal conditions. fter  months of treatment, the
aligner compatibility and the crown and root positions were
all consistent with the computer-simulated predictions
igs. . and .1.
In the nal stages of renement, the occlusal contact of
all upper and lower molars and a one-to-two-tooth occlusal
relationship in the buccal segments were conrmed. oth
the overbite and overet were 1 mm.
fter a total 1 months of treatment, all buttons, hooks,
and attachments were removed ig. .11. The patient was
instructed to wear class II elastics at night for an additional
1 months.
Treatment Results
The patient’s chief complaint—the infralabioversion of the
canines—was resolved, and the improvement in gingival
esthetics yielded a pleasant smile igs. .1, .1, and
.1. ue to the retraction of the maillary incisors, the
upper lip was particularly natural and relaed, and the lips
were positioned appropriately in relation to the -line. 
class I molar relationship with symmetric arches was
achieved, and all spaces were closed ig. .1. The physi-
ologically correct overbite and overet were coincident with
the dental and facial midlines.
88 Principles and Biomechanics of Aligner Treatment

Fig. 8.8 Treatment progresses in the frontal ie.

Fig. 8.9 Treatment progresses in the right ie.

 8 • Aligners in traction Cases 89

Fig. 8.9, cont’d

Fig. 8.10 Treatment progresses in the occlusal ies.

Continued
90 Principles and Biomechanics of Aligner Treatment

Fig. 8.10, cont’d

Fig. 8.11 Posttreatment pictures.


Fig. 8.12 Final smile esthetic analsis.
The posttreatment protrusive and lateral movements of
the mandible were smooth and linear. It is likely that the
patient was using considerable force when biting in centric
occlusion due to nervousness during the initial eamina-
tion. anoramic -rays conrmed that there was no change
in the level of the alveolar bone, which remained stable and
in a healthy condition. o signs of root resorption were
noted.
 cephalometric analysis indicated that the mandibular
plane angle was slightly reduced. uperimpositions showed
that while the upper and lower incisors were retruded, their
aes were upright and closer to the norm.
Discussion
ligners appeal to adults because of their pleasing aes-
thetics and their ability to produce gradual tooth move-
ments with light forces over the course of time. The focus
of previous reports has been on cases that did not reuire
etractions or those with only partial etractions. This is
perhaps due more to the difculty of closing spaces with-
out crown tipping than to the difculty of moving teeth.
hen etraction spaces are closed with aligners, a bowing
effect is often caused by the sagging of the plastic around
the etraction sites. This effect can be prevented by using
8 • Aligners in traction Cases 91
B
Fig. 8.13 (A) Final orthopantomograph. (B) Final lateral -ra.
class II elastics to enhance intermaillary anchorage. If
an elastic is attached directly to an aligner, however, the
plastic will separate from the teeth, making it more dif-
cult to maintain control over mesial and distal tooth
movements. In the case shown here, direct-bonded hooks
were attached to the upper canines to allow the teeth to
rotate both mesially and distally within the aligners, leav-
ing a margin of more than  mm between the incisal
edges and the aligners.
ather than attach the elastics in the mandibular arch
which was serving as anchorage directly to the aligners,
they were attached to buttons on the buccal surfaces of the
rst molars. This kept the aligners from lifting off the teeth,
while vertical rectangular attachments on the mesial edges
of the molars prevented mesial angulation. This avoided
the tipping of the teeth adacent to the mandibular etrac-
tion sites.
ecause the patient found the original predicted length
of treatment unacceptable, rthoulse- was used in
conunction with the aligners to possibly accelerate
treatment time. espite the lack of published accounts of
the effectiveness of this device beyond its application to
fied appliances, the patient was instructed to use it for
1 minutes every evening. e were able to shorten the
interval between aligner changes to  days, resulting
in a remarkable reduction in the treatment time to ust
92 Principles and Biomechanics of Aligner Treatment

Fig. 8.14 Posttreatment etraoral pictures.

 8 • Aligners in traction Cases 93

Fig. 8.15 Final stage of the ClinChec renement.

1 months. The patient eperienced no discomfort from
the rthoulse device or from the faster aligner changes.
he finished treatment with no interferences in protru-
sive or lateral mandibular movements and no esthetic
concerns.
Conclusion
ot only are aligners aesthetically pleasing to adult pa-
tients, but the ease with which they can be removed makes
them etremely safe. In the future, aligners are likely to
be used in more comple cases involving rotations, deep
94 Principles and Biomechanics of Aligner Treatment
overbites, open bites, and unusual etractions. urther
clinical investigations into the effects of accelerated tooth
movement in such cases are reuired.
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. arvalho-obato , arcia , asem , et al. Tooth movement in
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1:-.
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. ima , an , umagai , et al. pper molar distaliation with In-
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11:-.
. ima , an , umagai , et al. ccelerated etraction treatment
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:11-1.
 9 Open-Bite Treatment
with Aligners
ALDO GIANCOTTI and GIANLUCA MAMPIERI
In recent years, aligners have shown to be an extraordinary
and effective tool to correct open-bite cases. Such unex-
pected results make them the gold standard in the treat-
ment of malocclusions characterized by vertical excess as
in open-bite cases. Open bite is challenging to treat for its
multifactorial etiology and for high incidence of relapse.
he aim of this chapter is to show strategies and protocols
for the treatment of anterior open bite by clear aligners.
Diagnosis of Anterior Open Bite
Obviously, a proper diagnosis is essential in determining
the appropriate corrective measures. It is possible to classify
three types of open bite
. ental
. entoskeletal
. Skeletal
enerally, skeletal open bite reuires an orthosurgical
approach. Instead, dental and dentoskeletal open-bite cases
can be treated only by means of orthodontics. 
Biomechanics for Anterior
Open-Bite Correction
he biomechanics for anterior open-bite correction can be
achieved either by extruding the incisors or intruding the
posterior teeth, or by a combination of both. or the nonsur-
gical treatment of adult patients, some guidelines consider
extraction and retraction for dental open-bite correction. 
limited number of open-bite cases is suitable for such type of
treatment.
ental open-bite cases are mostly associated with the
following characteristics
n ormal craniofacial pattern
n Incisor proclination
n ndererupted anterior teeth
n ittle or no gingival display on smile
n o more than  to  mm of upper incisor exposure at rest
If the anterior open bite depends only on tooth position,
it is a relative open bite the biomechanics for the correction
are easy, as follows
n educing incisor proclination to produce a relative extrusion
n ure extrusion of incisors by extrusive attachments
he amount of incisal and gingival display needs to be
assessed clinically prior to deciding if pure extrusion is
desired from a smile esthetics point of view.
hen dentoskeletal factors are important in determining
the cause of open bite, it is often caused by posterior dento-
alveolar excess as well as by both downward and backward
mandibular rotation.- hese types of open bite with a
skeletal component caused by heredity andor supererupted
posterior teeth reuire complex orthodontic treatments
with active molar intrusion or even maor orthognathic
surgery.,
In case of a dentoskeletal open bite, specic procedures
have been designed to intrude posterior teeth or, at least,
prevent molar eruption or extrusion in the attempt to re-
duce or control anterior facial height, especially during the
growing age high-pull headgear, lower transpalatal arch
with resin button, and posterior bite blocks. he introduc-
tion of temporary anchorage devices s has allowed an
active intrusion of posterior teeth also in adult patients
with a conseuent mandibular counterclockwise rotation
and improvement of anterior open bite.
xtraction of posterior teeth is another strategic ap-
proach to correct anterior open bite. Indeed, when indi-
cated, molar extraction for caries or periodontal reasons
could be highly effective in reducing facial height. orward
movement of the terminal molars allows the mandible to
hinge upward and forward. It has been postulated that
 mm of intrusive vertical movement of the molars results
in approximately  to  mm of bite closure by mandibular
counterclockwise rotation.
In the treatment of a dentoskeletal open-bite case, one
shall observe some biomechanical principles. ny proce-
dure meant to increase facial height by means of extrusion
of posterior teeth must be avoided. eveling the arches is
usually not to be considered appropriate, and the mainte-
nance or creation of a curve of Spee would be desirable.
urthermore, banding of second molars should be avoided
to prevent any extrusion movement when molars are
engaged on the arch wire.
he abovementioned scenario can be easily avoided by
using aligners, which allow for nonextrusion and represent
a great advantage during open-bite treatment. his is
why a number of researchers consider aligners as the gold
standard.
Aligner Protocols for Open-Bite
Treatment
CLINCHECK SOFTWARE DESIGN
he clear aligner treatment of open-bite cases depends on the
type of malocclusion reuiring correction, and specic bio-
mechanics have to be reuested by checking the appropriate
95
96 Principles and Biomechanics of Aligner Treatment
boxes on the prescription form of the linheck software pro-
gram to generate a predictable linheck plan.
ental open bite, also known as relative open bite, clini-
cally features excessive incisor proclination it can be treated
only by reducing incisor proclination, producing a relative
extrusion of anterior teeth. or these movements, attach-
ments are not strictly reuired.
he rst step consists of recovering the needed space in
both arches. Space can be gained by arch expansion andor
interproximal reduction I. he decision depends on the
shape of the arches, tooth dimension, periodontal struc-
ture, and condition. ligners can easily modify the shape of
the arch, and it is later possible to retract the incisors ob-
taining enough relative extrusion in mild open bite to solve
the issue.
ATTACHMENTS IN OPEN-BITE CORRECTION
In case of more severe dental open bites, anterior teeth
extrusion can be strategic. ndoubtedly, extrusion is the
Fig. 9.1 Optimized extrusive attachments of the Invisalign system.
Fig. 9.2 The anterior extrusive forces and reciprocal posterior intrusive forces work in synergy to correct the
anterior open ite.
most difcult movement to reproduce with aligners. In
such conditions, attachments play an important role to
determine tooth extrusion. ttachments and anchorage
optimized anterior extrusive attachments are automati-
cally placed on the incisors by the software when pure
extrusion of . mm or more is detected igs. . and
.. onventional extrusion attachments have a rectan-
gular shape with beveled edge toward the gingiva to allow
for optimal pressure from the aligner and then achieve
proper extrusion ig. .. hese attachments could be
positioned also on the palatal surface if aesthetic reasons
are a priority ig. .. Our experience suggests that the
use of rectangular-shaped attachments with beveled edge
toward the gingiva with the largest possible dimensions
in relation to the incisor and most incisal possible allowed
for an optimal control of relative and absolute incisor
extrusion.
nchorage attachments can have different shapes and
dimensions, according to the type andor number of teeth
involved.

Fig. 9. ectangular shape attachments with eveled edge toward
gingiva.
he dentoskeletal open-bite treatment complies to a more
complex protocol to correct the malocclusion. Indeed, in
this type of open bite, the skeletal structure shows a dento-
alveolar posterior vertical excess, which is responsible for
an increased lower facial height.
or this reason, anterior tooth extrusion alone is not
enough for correction, and one shall reduce the posterior
vertical excess by dental intrusion.
osterior dental intrusion results in a mandibular coun-
terclockwise rotation mainly responsible for the open bite’s
correction, which can be veried by nal cephalometric
values. he anterior extrusive forces and reciprocal poste-
rior intrusive forces work in synergy to close the anterior
open bite see ig. ..
he amount of posterior intrusion may range from less
than . mm to a maximum of . mm. eyond the range
of predictability for aligner movements, it may be necessary
to use s.
olar intrusion can be planned with aligners, and there-
fore we dene it as selective intrusion. he rst and second
molars in the upper arch and rst molars and bicuspids in
the lower arch are involved in the plan. he protocol related
to attachment placement for anchorage usually envisages
rectangular attachments on the molars and optimized ones
on bicuspids. s for intrusion teeth, the ofcial Invisalign
protocol does not include the use of attachments. Some
experienced clinicians prefer to add occlusal rectangular
attachments to increase intrusive components and thus
increase effectiveness see ig. ..
In more severe open-bite malocclusions, some clinicians
prefer to stage posterior intrusion seuentially for a more
predictable clinical outcome rst the maxillary second mo-
lars, then the rst molars, and then the second premolars.
n important aspect to make predictable planning
with aligners is to design an overcorrection. In the lin-
heck we have to see the nal virtual occlusion with
9 • OpenBite Treatment with Aligners 97
Fig. 9. Palatal attachments and occlusal attachments on upper
molars.
heavy anterior occlusal contacts and at least  mm of
positive overbite.
Our point of view concerning dental intrusion is that the
most important effect of aligners in reducing posterior ver-
tical excess is the bite-block effect, which is caused by two
layers of aligner material between posterior teeth. It al-
lows to effectively intrude posterior teeth, hence enabling
subseuent autorotation of the mandible and reducing
anterior facial height.
he bite-block effect cannot be uantitatively priorly
planned or displayed in the virtual digital setup by lin-
heck, but we can routinely observe it clinically, especially
in patients with a normal or larger mandible.
In nal, to guarantee the maintenance of the result over
time, it is essential to use ivera, the clear retainer produced
by lign, because the posterior occlusal coverage will pre-
vent the reeruption of posterior teeth.
Case Report 1
CASE SUMMAR
 -year-old female patient presented a severe crowding,
an unpleasant smile, as well as speech issues. linical extra-
oral examination showed a convex skeletal soft tissue prole
due to a retrognathic mandible and incompetent lips at rest
with mentalis and lip strain when the lips were pursed to-
gether. Intraoral examination evidenced class II canine and
class I molar relationship on both sides, an anterior open
bite, an excessive incisor proclination, and crowding on
both arches ig. . able ..
ephalometric analysis showed increased mandibular
plane angle and increased lower anterior facial height see
able . later. osterior maxillary dentoalveolar heights
were dened as excessive ig. ..
9 Principles and Biomechanics of Aligner Treatment

Fig. 9.5 ase tudy  Initial clinical records.

 9 • OpenBite Treatment with Aligners 99

PROBLEM LIST

Table 9.1 ase tudy  Prolem ist

Dimension Seletal Dental Soft Tisse
Anteroposterior n onvex skeletal prole due to retrognathic mandile n lass II canine relationship n etrusive lower lip
and chin
n keletal class II n xcessive incisor proclination
ertical n Increased lower anterior facial height n Overite  mm n entalis muscle strain
at rest
n Increased mandiular plane angle n arrow upper arch
n Incompetent lips
n Increased maxillary posterior dentoalveolar heights
Transverse n arrow upper and lower arch

Fig. 9.6 ase tudy  Pretreatment xray records.

TREATMENT OBECTIES TREATMENT ALTERNATIES

he main treatment obectives were to close the anterior
open bite, obtain class I canine relationships, correct
the excessive incisor proclination, and improve smile arc
able ..
TREATMENT PLAN
he treatment of dentoskeletal open bite reuires closure of
anterior open bite through a combination of retraction and
extrusion of the upper incisors and by intrusion of poste-
rior maxillary dentition to enable subseuent autorotation
of the mandible with an improvement of vertical and sagit-
tal relationship.
dditional treatment goals included leveling and align-
ing, optimizing the posterior occlusion, aiming at class I
canine relationships, as well as ideal overbite and overet to
improve the facial prole and obtain natural lip competence
without mentalis strain.
he treatment alternatives consisted of the following
. Orthosurgical treatment, including a eort I osteotomy
with posterior maxillary impaction
. onventional treatment with intrusion of the posterior
maxillary dentition by using s for skeletal anchorage
. xtraction treatment to reduce the vertical dimension
while easing reduction of the anterior protrusion and
mandibular crowding
TREATMENT SEUENCE
orrection was achieved by means of the expansion of the
upper arch by  mm that allowed tooth alignment and the
correction of upper incisor proclination. In the lower arch,
molar and premolar torue was corrected. he optimized
attachments on cuspids and rst bicuspids in the upper arch
were programmed to perform the anchorage unit necessary
1 Principles and Biomechanics of Aligner Treatment
Table 9. ase tudy  Treatment Oectives
Dimension Seletal
Anteroposterior n educe skeletal convexity with
autorotation of the mandile
ertical n educe lower facial height and man
diular plane angle y intruding the
maxillary and mandiular posterior
teeth and autorotating the mandile
Transverse
to achieve the reuired reduction of incisor proclination
gaining enough space by means of I and arch expansion.
Intrusion of posterior teeth determined by aligners would
have favored a counterclockwise rotation of the mandible,
thus promoting the anterior open-bite correction ig. ..
Open-bite correction occurred by means of a rst phase of
 aligners and a nishing stage including  aligners. In
addition, the expansion, together with the correction of the
tipping of cuspids and bicuspids, allowed for coordination of
both arches and a slight mesial mandibular repositioning
with an optimization of the occlusal relationships and cor-
rection of class II canine malocclusion.
TREATMENT RESULTS
fter  months of therapy, treatment obectives set in the
pretreatment plan were achieved. he anterior open bite
had been completely closed, a proper overbite and overet
Fig. 9.7 ase tudy  Pre and postlinheck superimposition.
Dental Soft Tisse
n Improve class II canine relationship n Improve soft tissue prole
y autorotation of the mandile
n Improve anterior overite and smile n educe interlaial gap
arc y intruding upper posterior n Improve the prole y intruding
teeth and maintaining the vertical
maxillary dentoalveolar sites.
position of the anterior teeth.
n Achieve lip closure without activation
of mentalis muscles
n xpand upper and lower arch
had been corrected, and class I canine relationship had
been established ig. ..
he extraoral records show an evident improvement in the
patient’s smile. he pre- and posttreatment cephalometric
showed  mm of intrusion of the upper molars determined
by aligners. Such dental movement resulted in a mandibular
counterclockwise rotation mainly responsible for the closure
of the anterior open bite and the reduction of vertical skeletal
values in the nal cephalometric assessment. aused by two
layers of aligner material between the posterior teeth, molar
intrusion is identied by clinicians as the bite-block effect and
enables not only the correction of anterior open bite by
means of the mandible’s counterclockwise rotation, but also
an improvement of the class II relationship, thanks to man-
dibular repositioning ig. . able ..
ollow-up after  months showed the great stability of the
results ensured by means of ivera retainers. he use of
aligners for retention provides a long-term posterior intrusive
 9 • OpenBite Treatment with Aligners 11

Fig. 9. ase tudy  inal clinical records.

12 Principles and Biomechanics of Aligner Treatment

Fig. 9.9 ase tudy  Posttreatment xray records.

Table 9. ase tudy  ummary of ephalometric hanges

Cephalometric orphologic Assessment ean SD Pretreatment Posttreatment
SAGITTAL SKELETAL RELATIONS
axillary position A ° 6 . ° °
andiular position B ° 6 . ° °
agittal aw relation AB ° 6 . ° °
ERTICAL SKELETAL RELATIONS
axillary Inclination AP ° 6 . ° °
andiular inclination O ° 6 . ° °
ertical aw relation APO ° 6 . ° °
DENTOBASAL RELATIONS
axillary incisor inclination AP ° 6 .° ° °
andiular incisor inclination oge ° 6 .° ° °
andiular incisor compensation AP   6 .  
DENTAL RELATIONS
Overet  . 6 .  
Overite   6 .  
Interincisal angle  ° 6 . ° °

force similar to that of posterior bite blocks, which is rec-
ommended for vertical control after anterior open-bite
treatment.
Case Report 
CASE SUMMAR
 -year-old female presented with a mild skeletal
class II, division  malocclusion, moderate lower and
mild upper crowding, moderate anterior open bite, a
severely hyperdivergent skeletal pattern, and an unbal-
anced transverse relationship. linical examination in-
dicated excessive lower facial height with a gummy
smile and a typical long-face appearance ig. .
able .. he patient had a -mm anterior open bite,
with posterior occlusion only on the second molars.
adiographic examination confirmed the vertical excess
in the lower face ig. .. wo treatment options
were presented surgical correction or aligner therapy
with s.
 9 • OpenBite Treatment with Aligners 1

Fig. 9.1 ase tudy  Initial clinical records.

1 Principles and Biomechanics of Aligner Treatment

PROBLEM LIST

Table 9. ase tudy  Prolem ist

Dimension Seletal Dental Soft Tisse
Anteroposterior n keletal class II division  malocclusion n Occlusal contacts only on the second n etrusive lower lip and chin
molars
n xcessive incisors proclination
ertical n Increased lower anterior facial height n oderate anterior open ite mm n ong face type
n xcessive maxillary posterior growth n ummy smile
n evere hyperdivergent pattern n entalis muscle strain at rest
Transverse n Transversal skeletal deciency n oderate lower and mild upper
crowding
n nalanced occlusion relationships

Fig. 9.11 ase tudy  Pretreatment xray records.

TREATMENT OBECTIES
he treatment aim was to close anterior open bite, correct
excessive vertical facial height, obtain balanced occlusal
contacts with a class I molar relationship, and improve pa-
tient’s smile able ..
he treatment also included the achievement of class I mo-
lar relationships, dental alignment and leveling, optimization
of posterior transversal occlusion, as well as reaching ideal
overbite and overet to improve the facial prole and smile arc.
he pre- and postvirtual plan is shown in ig. .

TREATMENT PLAN TREATMENT ALTERNATIES

he skeletal class II and the anterior open bite reuired cor-
rection by counterclockwise rotation of the mandible al-
lowed by maxillary molar intrusion, without moving the
vertical position of anterior teeth. Such upward and for-
ward rotation would reduce facial height and improve verti-
cal and sagittal relationships with proper dental torue and
inclination.
he treatment alternatives consisted of the following
. Invisalign therapy with intrusion of the posterior maxil-
lary and mandibular dentition by using s as skeletal
anchorage
. Orthosurgical treatment including a eort I osteotomy
with posterior maxillary impaction
 9 • OpenBite Treatment with Aligners 15

Table 9. ase tudy  Treatment Oectives

Dimension Seletal Dental Soft Tisse
Anteroposterior n Improve class II y counterclockwise n Improve class II molar relationship and incisor n Improve soft tissue prole
mandiular rotation induced y inclination y counterclockwise mandiular
molar intrusion rotation induced y molar intrusion
ertical n educe lower facial height maxillary n Improve anterior overite and smile arc y n Improve the prole y
downward clockwise rotation and intruding upper posterior teeth and maintain intruding maxillary
hyperdivergent pattern y intruding ing the vertical position of the anterior teeth dentoalveolar sites
upper posterior teeth and conse
uent autorotation of the mandile
Transverse n xpand maxillary arch dentally n Improve alanced occlusion relationships y
mandile autorotation
n educe upper and lower crowding y contact
points stripping

TREATMENT SEUENCE
he patient chose the second option. osterior maxillary
dentoalveolar intrusion for vertical correction was achieved
by miniscrew mechanics. uccal  mm 3  mm Spider in
miniscrews were placed mesially to each maxillary rst
molar. n auxiliary . in 3 . in stainless steel
sectional wire was placed on each side of the working cast
coated at the ends with composite resin for easier place-
ment in the mouth.  surgical hook was crimped at each
rst molar and -g nickel titanium coil springs were tied
from these to the s. o avoid the development of unde-
sirable molar labial torue due to the force application on
the buccal side only, the plan included use of upper and
lower aligners to control it. he digital treatment plan was
designed for alignment, I, and, if needed, tooth retru-
sion. Instead, posterior intrusion and anterior extrusion, or
other vertical movements as in ase , were carefully
avoided because the difference between  and aligner
mechanics could lead to imperfect aligner t and inade-
uate torue control ig. .. he aligner treatment
consisted of  upper and lower aligners, plus  upper
and lower renement aligners. ustomized, precise cuts of
the aligners were designed on the linheck to accommo-
date the auxiliary wires, usually affecting two or three teeth
on each side.

TREATMENT RESULTS
deuate intrusion and conseuent closing of open bite
were achieved in  months with dental alignment and lev-
eling ig. ..
oals set in the pretreatment plan were totally reached
after  months of therapy ig. . able .. he ante-
rior open bite had been completely corrected, resulting in a
proper overbite and overet.  class I molar relationship had
been established.
atient’s smile positively changed by improving vertical
lower facial height and gummy smile. he values in the nal
cephalometric assessment show a -mm intrusion of the up-
per molars and reduction of the vertical skeletal determined
Fig. 9.12 ase tudy  Pre and postlinheck superimposition.
by aligners ig. . see able ..
16 Principles and Biomechanics of Aligner Treatment

Fig. 9.1 ase tudy  Invisalign with temporary anchorage devices

for posterior intrusion.

Fig. 9.1 ase tudy  nd of posterior intrusion.

 9 • OpenBite Treatment with Aligners 17

Fig. 9.15 ase tudy  inal clinical records.

1 Principles and Biomechanics of Aligner Treatment

Table 9. ase tudy  ummary of ephalometric hanges

Cephalometric orphologic Assessment ean SD Pretreatment Posttreatment
SAGITTAL SKELETAL RELATIONS
axillary position A ° 6 . ° °
andiular position P ° 6 . ° °
agittal aw relation AP ° 6 . ° °
ERTICAL SKELETAL RELATIONS
axillary inclination AP ° 6 . ° °
andiular inclination O ° 6 .  ° °
ertical aw relation APO ° 6 . ° °
DENTOBASAL RELATIONS
axillary incisor inclination AP ° 6 . ° °
andiular incisor inclination O  6 . ° °
andiular incisor compensation AP   6 .  
DENTAL RELATIONS
Overet  . 6 .  
Overite   6 .  
Interincisal angle  ° 6 . ° °

Fig. 9.16 ase tudy  adiographic control and cephalometric superimposition.

. Sarver , eissman S. onsurgical treatment of open bite in non-

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. uhn . ontrol of anterior vertical dimension and proper selection
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 10 Deep Bite
LUIS HUANCA, SIMONE PARRINI, FRANCESCO GARINO,
and TOMMASO CASTROFLORIO
Introduction
Deep bite is dened as an increase of the overbite, and it is
measured as vertical overlap of the incisors perpendicular to
the occlusal plane.1,2 It can be divided into dentoalveolar
origin (overeruption of frontal teeth) and skeletal origin
(decreased lower face height, low mandibular plane angle).
Deep bite prevalence varies from  to 1 depending on
the threshold values applied, ethnic group, and gender.–
 correlation between deep bite and sagittal molar mal
occlusion was described. In particular, class II molar maloc
clusion is signicantl associated with increased overbite
compared with class I malocclusion.
egarding treatment strategies in deep bite patients,
there is not a complete consensus in the eisting literature.
 21 review published b illet et al. assessed that it is
not possible to provide an evidencebased guidance to rec
ommend or discourage an tpe of orthodontic treatment
to correct class II, division 2 malocclusion in children.
s assessed b anda,1 it is possible to adopt three differ
ent therapeutic strategies etrusion of posterior teeth, intru
sion of upper andor lower incisors, and aring of anterior
teeth (also known as relative intrusion). ll these effects can
be obtained together depending on the clinical case.
 using clear aligners instead of ed appliance, the
orthodontist can start correcting the overbite on both
arches from the beginning rather than wait a few months
to bond the lower arch after the upper teeth have been
aredintruded to open the bite. he alternative would be to
bond bite ramps since the beginning, but these ma prove
uncomfortable for patients and reuire adustments and
etra cleanup at some point in the future.
Leveling of the Curve of Spee
 deep curve of pee is often associated with severe anterior
deep bite.  etruding posterior teeth, mainl premolars,
and intruding anterior teeth, it is possible to atten the
arches and achieve an ideal overbite.1
It is difcult to dene the net contribution of molar and
premolar etrusion versus canine and incisor intrusion to
the overall curve of pee attening, as the act as a recipro
cal source of anchorage. henever attempting to etrude
the premolars, canines and incisors will serve as an anchor
age unit, and the will pa the price of a most welcome in
trusion side effect. n the contrar, ever time clinicians
would love to achieve intrusion of the anterior teeth, the
premolars represent the primar source of anchorage, and
the ma etrude a benecial side effect of anterior intru
sion. ven if, b using clear aligners and an attentive plani
cation of tooth movements, clinicians ma be persuaded
that the can achieve specic tooth movements (i.e., intru
sion of the anteriors onletrusion of the posteriors onl),
the should be aware that ewton’s third law of phsics
(action and reaction) plas an important role in distin
guishing the real world from the virtual onscreen world of
setup, where the laws of phsics are often violated.
It is a common belief that deep bite correction and curve
of pee attening is easier to achieve in growing patients, as
etrusion of molars and premolars can be supported b
vertical growth while grow is still happening.
n the contrar, curve of pee correction in adults ma
be much harder, as the orthodontist cannot hope in an
inuence or help from the vertical skeletal dimension. ur
thermore, curve of pee tends to deepen with aging, with
supererupted lower incisors and canines that ma also show
lingual inclination (upper incisors can also show lingual incli
nation as a conseuence). his becomes clinicall evident in a
twostep mandibular occlusal plane with a net step between
the rst premolars and canines. cessive wearing of the inci
sal edges ma also be evident in such circumstances. hile
planning deep bite correction in an adult, the orthodontist
should also plan an eventual restorative treatment that is
needed to reestablish the proper crown anatom.
lign echnolog has created a proprietar protocol for
deep bite correction called Invisalign . his protocol in
volves incisor and canine intrusion through a combination
of intrusion forces eerted b the aligners on the occlusal
edge of the teeth and a pressure area on the lingual surface
(igs. 1.1 and 1.2). his combination of force sstems
eerts a nal intrusive force that is supposed to be parallel
to the tooth long ais. o achieve the desired intrusion on
the anterior teeth, an adeuate anchorage should be pro
vided in the premolar and molar area.  retention attach
ments have been specicall designed for premolars, and
the ma serve as pure anchorage attachments or as active
etrusion attachments in case of etrusion of the premo
lars. oth movement of anterior intrusion and posterior
etrusion are automaticall activated if the threshold of
movement is more than . mm. olar anchorage should
be provided with conventional attachments (rectangular
and horiontal) to counteract the occlusal movement of the
aligner determined b the anterior intrusion design.
linicians working with other clear aligner sstems than
Invisalign, or those who feel the need for alternative ap
proaches even when using Invisalign aligners, ma create a
similar protocol using standard attachments and a person
alied staging of intrusion.
ingival beveled attachments ma be used as an alterna
tive to  retention attachments on premolars to achieve
retention and etrusion. hen planning etrusion, it is
109
110 Principles and Biomechanics of Aligner Treatment
Fig. 10.1 Schematic representation of the optimized bite ramps de-
signed by Align Technology (San José, CA, SA and embedded into
aligners They change shape and positioning along the treatment to
proide optimal spport to loer incisors at eery stage of treatment
Pressure area
Aligner forces
Resultant force
Fig. 10.2 Schematic representation of pressre areas designed by
Align Technology (San José, CA, SA and incorporated into the aligner
to redirect the intrsie force along the long ais of the incisor
useful to ask for a slower etrusion rate (e.g., .1 mm per
stage instead of the classic .2 mm) to avoid lack of track
ing within the aligner b respecting the phsiologic toler
ance of the periodontal ligament.
ome clinicians recommend a superiorl conve (reverse)
curve of pee as nal obective of the alternative. hile this
is not the real clinical goal, the assumption behind this pre
scription is that the elasticit and resilience of the plastic
material will ver unlikel allow a full epression of the
prescribed movement.  the wa the lack of epression of
certain movements can be compensated b this reuested
hpercorrection, that is the aligner euivalent of the re
verse curve ii wires.1 he clinician who has the feeling
that the hpercorrection is reall happening ma alwas
stop the use of the aligners to avoid unwanted side effects.
urve of pee correction should alwas begin with lower
incisor proclination to obtain a relative intrusion and start
to recover the space reuired during the real intrusion
movement. ince the epression of the lingual root torue
information on lower incisors has not et been investigated,
it can be useful to prescribe etra lingual root torue.
gain, it is important to remember that interproimal spac
ing ma help the intrusion movements.
 paper b iu and u11 eplained how force changes as
a conseuence of different intrusion strategies for deep bite
correction with clear aligners. ith the same activation
(.2 mm of intrusion) and rectangular attachments placed
on the premolars and rst molars, the canines eperienced
the largest intrusive force when intruded alone. hen ap
pling contemporar intrusion of canines and incisors, the
canines received a larger intrusive force than incisors. he
incisors received similar forces of intrusion if intruded
alone or together with canines. irst premolars eperienced
the largest etrusive forces when all anterior teeth were in
truded. trusion forces were eerted also on canines and
lateral incisors when differential staging for intrusion of
canines and incisors was used. It is not surprising that the
intrusive force eerted b clear aligners is higher when less
elements are involved, and it is partiall lost when multiple
elements are intruded at the same time. he incisors show
an overall scarce tendenc to feel intrusion forces. his ma
lead to the clinical suggestion of a staggered approach, al
ternating canine and incisor intrusion to eert higher and
more specic forces on canines and incisors.
herefore, a clinical suggestion in prescribing anterior
intrusion with an clear aligner sstem could consider the
following
1. Intrusion from canine to canine at a rate of .1 mm
per stage (rst create an etra space of . mm to hold
until the movement has been completed)
2. oriontal rectangular beveled gingival attachments on
lower bicuspids those attachments should be  mm
wide, 1. mm high, 1.2 mm thick at the gingival mar
gin, and tapered to .2 mm thickness at the occlusal
margin
. oriontal rectangular beveled occlusal attachments on
lower canines those attachments should be  mm wide,
1. mm high, 1.2 mm thick at the occlusal margin,
and tapered to .2 mm at the gingival margin
. oriontal rectangular attachments on molars to increase
anchorage
. lternate intrusion of canines and incisors
. lace the attachments occlusall avoiding an interarch
interferences
Leveling the Upper Incisors
linical observation of patient face and smile and gingival
displa guide the clinician in the choice of how to correct
an ecessive overbite.12 In fact, in man clinical cases, a
pure lower posterior etrusioncurve of pee attening
ma not be the best option, but the mechanics in the lower
arch should be accompanied b vertical movements on the
upper anteriors. During treatment planning with aligner
orthodontics, it is possible to prescribe a selective upper or
lower incisor intrusion.
It is not surprising that when tring to correct an eces
sive overbite, the upper smile arch needs special care, as Dr.
David arver taught to the whole profession. he intrusion
of the upper incisors should be limited to preserve conveit
of the smile and enough crown eposure to preserve a
outhful smile while aging.
pper incisors and canines ma be intruded b relative
intrusion (i.e., b providing vestibular crown torue, some
intrusion happens as a geometric conseuence of this move
ment). o allow a full epression of this movement, it is
strongl suggested to prescribe an etra lingual root torue.
ower idge (lign echnolog, an osè, , ) at the
gingival third of the crown ma also help in achieving
 10 • eep Bite 111

labial crown torue. imon et al.1 demonstrated that even a

buccal attachment on upper incisors could provide lingual
root torue control.
pper relative intrusion and incisor crown vestibularia
tion is often needed in those adults who have a ver deep
curve of pee, where the correction starts with labial move
ment of the lower incisors. nough clearance (anterior
overet with no contacts) should be provided to avoid poste
rior disclusion due to hard collisions among upper and
lower incisors due to occlusal interferences.
nce achievement of the correct amount of relative
intrusion occurs, pure intrusion can be applied. ith
lign echnolog  protocol, when the intrusion reuest
overpasses the .mm threshold, a lingual pressure area
will be added to enhance the parallelism of the nal vector
of intrusive force to the long ais of the tooth.
ite ramps ma be added on the lingual part of the teeth
to help during deep bite correction (see ig. 1.1). he are
optimied—in other words, the can change shape and
position during the different stages of treatment to keep
contact with the lower incisors as a conseuence of upper
incisor buccal crown torue (the get longer while the up
per incisor crowns get ared). hen bite ramps are present,
no palatal pressure areas can be added at the same time on
the same tooth as the two features need some space on the
lingual surfaces of incisors andor canines. here are some
claims of a possible intrusive effect of bite ramps on upper
incisors because of the imposed precontact. hile this
claim ma answer a logical thought, it is important to re
member that we pass most of the time in a discluded posi
tion of the aw respecting our vertical freewa space. s a
conseuence, patients bite over the bite ramps for a few
seconds per da onl when swallowing, thus the real effect
of bite ramps as booster of upper intrusion is uestionable.
he wa bite ramps keep the aws constantl discluded is
the same principle of man functional appliances, whose
main obective is to enhance lower posterior etrusion b
providing an anterior precontact. In this sense, bite ramps,
supported b class II elastics, ma favor lower posterior
teeth etrusion, especiall in growing patients. It is impor
tant to notice that, with aligners, elastics are recommended
to boost posterior etrusion, as the clear aligner is other
wise creating a selflimiting barrier that can limit posterior
etrusion. n the contrar with functional appliances,
where the molars and premolars are left free to erupt, the
posterior vertical correction happens naturall.
eviewing the eisting literature about deep bite correc
tion with aligners, hosravi et al.1 showed that in their
sample of  deep bite patients treated with Invisalign
aligners, the cephalometric analses performed to deter
mine the mechanism b which the Invisalign appliance
corrects deep bites suggest that proclination of mandibular
incisors, along with intrusion of maillar incisors and
etrusion of mandibular molars, is the primar source of
deep bite correction with the Invisalign appliance.

Case Report 1
he patient presented at the age of 1 with a severe over
bite, a deep curve of pee associated with lower crowding,
and important lingualiation of the lower right canine
Fig. 10.3 nitial etraoral photos
(igs. 1. and 1.). is chief complaint was to avoid the
112 Principles and Biomechanics of Aligner Treatment
Fig. 10.4 nitial intraoral photos
traumatism he felt ever time he bit on the palatal mucosa
close to the retroincisal papilla.
s visible on tracings, he had a slight class II while the
skeletal vertical dimension was not as severel reduced as
the dental deep bite could have suggested. e had agenesis
of the second lower premolars (ig. 1.).
he treatment plan included the preservation of the
lower second deciduous molars and eventual implant
substitution of second premolars later in life.
he treatment lasted 2 months with four sets of correc
tions of decreasing length. he length of the treatment was
due to the severe curve of pee that needed a big effort to be
attened. ligner change was planned ever  das from
the beginning. he curve of pee attening was obtained
rst with proclination of the lower incisor and relative in
trusion, then space was created mesial and distal to lower
incisors and canines, and maintained while performing in
trusion with staggered alternate movements (frog protocol)
(ig. 1.). nchorage attachments (rectangular horion
tal) were used on the premolars but also on the canines,
as at moments the served as anchorage unit for incisor
intrusion (ig. 1.).
 10 • eep Bite 113

A B

Fig. 10.5 (A nitial orthopantomography (B nitial lateral -ray

C (C nitial tracing

Fig. 10.6 Treatment stages scheme illstrating the frog protocol in hich alternate intrsion moements of canines
and incisors are planned n the  ais teeth are displayed, hile on the  ais treatment stages are displayed eery
stage corresponds to e aligners The blue lines indicate actie moements, brown lines indicate oercorrection
stages Red arrows down indicate hen attachments shold be placed, hile red arrows p indicate hen attachments
shold be remoed
114 Principles and Biomechanics of Aligner Treatment

A B

Fig. 10.7 (A nitial cre of Spee (B inal cre of Spee

he deep bite was full corrected on the lower arch
(igs. 1., 1., and 1.1), as superimpositions on the
ellaasion plane (ig. 1.11) show an unaltered verti
cal position of the upper incisors. n important intrusion
of the lower incisors is associated with a slight advance
ment of the  point of the mandible probabl due to the
use of class II elastics.
Due to the presence of the lower deciduous molars, the
patient ended into a canine class I and molar headtohead
relationship. he lower right deciduous molar responded
perfectl to the therap, while the left one was uite unre
sponsive to vertical movement, and a slight underbite was
left at this level. he patient’s chief complaint of retroinci
sal traumatism was full achieved.

Fig. 10.8 inal etraoral photos


Case Report 2
n 1earold male patient presented with molar class II
malocclusion, skeletal class II, low mandibular plane angle,
deep bite with an increased curve of pee, and crowding
in the incisor area (igs. 1.12 and 1.1). atient’s main
concern was the deep overbite and crowding in the upper
incisors area.
he treatment plan was designed to obtain bodil distal
movements of upper molars, premolars, and canines to
achieve a dental molar and canine class I.
10 • eep Bite 115
Fig. 10.9 inal intraoral photos
  seuential distaliation protocol was applied
together with the use of class II elastics (.1 in, . o)
during the distaliation process (see hapter ).
ttachments were placed on all distaliing teeth to con
trol bodil distal movements (igs. 1.1 and 1.1).
he deep bite was corrected mainl through intrusion of
the lower anterior teeth, using the  protocol, and the
presence of bite ramps on the upper incisors.
he amount of lower intrusion in the incisor area was
.1 mm, and to reinforce the posterior anchorage, attach
ments were placed on bicuspids.
116 Principles and Biomechanics of Aligner Treatment

A B

C Fig. 10.10 (A inal orthopantomography (B inal lateral -ray (C inal
tracing

 set of  Invisalign aligners was produced to perform

the distaliation movements on the upper arch and to cor
rect the lower curve of pee. ligner change was planned
ever 2 weeks at the beginning of treatment, ever 1 das
after  months of treatment, then ever  das after  months
of treatment. During the distaliation phase, the patient was
instructed to wear class II elastics (.2 in, . o) bilaterall
to reinforce anterior anchorage while distaliing premolars.
o anchor class II elastics, hooks were planned on upper
canines while buccal tubes were bonded on the lower rst
molars.
n additional set of 1 upper and lower aligners was
reuested to nalie the treatment obtaining good nal
intercuspation in the molar and bicuspid areas and a nal
overet of 2 mm.
he treatment was concluded with bilateral class I molar
and canine relationship, ecellent upper and lower align
ment, and good leveling of the curve of pee (igs. 1.1,
1.1, and 1.1).
Fig. 10.11 Tracing sperimposition
he total treatment duration was 2 months.
 10 • eep Bite 117

Fig. 10.12 nitial etraoral photos

Fig. 10.13 nitial intraoral photos

118 Principles and Biomechanics of Aligner Treatment

A B

Fig. 10.14 (A nitial orthopantomography (B nitial lateral -ray

Fig. 10.15 n progress intraoral photos olar tbes ere sed on

loer rst molars for class  elastic anchorage
 10 • eep Bite 119

Fig. 10.16 inal etraoral photos

Fig. 10.17 inal intraoral photos

120 Principles and Biomechanics of Aligner Treatment
A B
Fig. 10.18 (A inal orthopantomography (B inal lateral -ray
References
1. anda . Biomechanics and Esthetic Strategies in Clinical Orthodontics.
aunders 2.
2. Dan , reuter , ifakakis I, et al. tabilit and relapse after orth
odontic treatment of deep bite cases—a longterm followup stud.
Eur J Orthod. 21222.
. ielsen I. ertical malocclusions etiolog, development, diagnosis
and some aspects of treatment. Angle Orthod. 111()22.
. u , Dücker , ritsch , et al. cclusal status and prevalence of
occlusal malocclusion traits among earold schoolchildren. Eur J
Orthod. 2122.
. roft r , ields , arver D. Contemporary Orthodontics. th ed.
lsevier 21.
. ausche , uck , arer . revalence of malocclusions in the earl
mied dentition and orthodontic treatment need. Eur J Orthod.
22()22.
. illett D, unningham , ’rien D, et al. rthodontic treatment
for deep bite and retroclined upper front teeth in children. Cochrane
Database Syst Rev. 21(2)D2.
. ans , nlow D. Essential of Facial roth. eedham ress 1.
. arshall D, aspersen , ardinger , et al. Development
of the curve of pee. Am J Orthod Dentofac Orthop. 21()
2.
1. lifford , rr , urden D. he effects of increasing the reverse
curve of pee in a lower archwire eamined using a dnamic
photoelastic gelatine model. Eur J Orthod. 121()21222.
11. iu , u . orce changes associated with different intrusion
strategies for deepbite correction b clear aligners. Angle Orthod.
21()1.
12. arver D. he importance of incisor positioning in the esthetic
smile the smile arc. Am J Orthod Dentofac Orthop. 2112(2)
111.
1. imon , eilig , chware , et al. reatment outcome and efcac
of an aligner techniue—regarding incisor torue, premolar derotation
and molar distaliation. BC Oral ealth. 211.
1. hosravi , ohanim , uoel , et al. anagement of overbite
with the Invisalign appliance. Am J Orthod Dentofac Orthop.
2111()1,e2.
 11 Interceptive Orthodontics
with Aligners
TOMMASO CASTROFLORIO, SERENA RAVERA, and FRANCESCO GARINO
Introduction
Early orthodontic treatment is still a debated argument. Ac-
cording to the existing literature, the usefulness of intercep-
tive orthodontics is controversial even if many sagittal,
vertical, and transversal malocclusions are clearly visible
and diagnosed in the early mixed dentition.1
Some authors recommend interceptive treatment because
many malocclusions tend to worsen with age.2 Some other
studies have underlined that orthodontic treatment during
the pubertal phase may positively inuence malocclusion
improvements, contributing to the stability of nal results.3
However, a recent review stated that removable functional
appliances can produce short-term good dentoalveolar ef-
fects rather than skeletal improvements.4 Furthermore, a re-
cent update of a Cochrane review claimed that on the basis
of low to moderate quality evidence, providing early orth-
odontic treatment for children with prominent upper front
teeth is more effective for reducing the incidence of incisal
trauma than providing one course of orthodontic treatment
in adolescence. There appear to be no other advantages of
providing early treatment when compared to late treatment.5
The reduction of upper incisor proclination should not
be underestimated because the smile appearance is impor-
tant among overall esthetics for adolescents as well as for
children younger than 10 years of age. Correcting smile
alterations, even in young children, may be fundamental in
preventing bullying or teasing from others and in improv-
ing the quality of social interactions, preserving healthy
psychologic development.6
Interceptive orthodontics could be also recommended when
detecting bad oral habits as atypical swallowing and mouth
breathing have been found to be strictly related to malocclusion
worsening.7 Moreover, early orthodontic treatment mainly
consisting in maxillary expansion and mandibular advance-
ment has been indicated to treat pediatric sleep apnea patients.8
The controversial results deriving from the existing litera-
ture in terms of effectiveness of interceptive orthodontics are
mainly related to the lack of specic indicators of the right
biologic timing of intervention. Although no skeletal matu-
rity indicator may be considered to have a full diagnostic reli-
ability in the identication of the maxillary growth peak and
of the pubertal growth spurt or mandibular growth peak,
treatment timing according to available indicators (mainly
hand and wrist maturation [HWM] and cervical vertebral
maturation [CVM] methods) has yielded more favorable out-
comes. The use of the HWM or CVM methods (or others) may
still be recommended for treatment planning, even though
large individual responsiveness and dentoalveolar compensa-
tions have been reported, even in pubertal patients.9
In this chapter, we focus on clear aligner interceptive or-
thodontics of class II retrognathic patients and of patients
with maxillary constrictions, highlighting the recommen-
dations for case selection and treatment planning, showing
some case reports.
Maxillary Expansion
Transverse maxillary constriction and maxillary crowding
in children are problems commonly encountered and
treated by orthodontists.10-12 Interceptive orthodontics
with maxillary expansion (ME) is one of the treatment op-
tions recommended for children with transverse decien-
cies with the intent to increase the transverse widths of the
maxilla. This approach is particularly important in children
with posterior crossbite because it has been shown to deter-
mine abnormal chewing patterns and the development of
skeletal asymmetries.13,14
Expansion is especially desirable for young class II division
I patients who have constricted maxillae because the trans-
verse deciency does not self-correct between the deciduous,
mixed, and permanent dentitions.15 Increasing maxillary
arch width could improve class II with retrognathic mandi-
ble, inducing a spontaneous forward repositioning of the
mandible, even if there is still a lack of general consensus on
this issue.16,17 Maxillary arches are also expanded routinely
to solve anterior crowding and improve the smile esthetics of
kids.6,18-20 Crowding of the permanent incisors, with associ-
ated rotations and/or anterior crossbite, is commonly ob-
served during eruption of the permanent lateral incisors.
The rationale of interceptive treatment in the early mixed
dentition is to generate adequate space for the spontaneous
alignment of the permanent upper lateral incisors prior to
complete eruption. When crowding is limited to a few milli-
meters, normal growth could provide adequate space, but
when the palate is narrow and the crowding exceeds this
amount, maxillary expansion could represent an effective
procedure.21 As stated by Rosa et al.,21 when planning inter-
ceptive rapid maxillary expansion (RME) in absence of poste-
rior crossbite, the clinician should consider that rst perma-
nent molars are often tilted buccally, and a further buccal
movement will produce periodontal problems and posterior
occlusal interferences related to the deepening of the Wilson
curve. Furthermore, the amount of anterior expansion could
not be enough to solve the anterior crowding. Ideally the
expansion should be limited to the anterior region of the arch,
while permanent molars should move in a palatal direction.
Considering these aspects, maxillary expansion by an-
chorage on deciduous teeth has been proposed. The benet
121
122 Principles and Biomechanics of Aligner Treatment

of anchoring the expander on second deciduous molars and

deciduous canines was the gain of 5 to 6 mm in upper arch
perimeter. The gained space is sufcient to solve anterior
crowding without tilting buccally permanent molars. How-
ever, those teeth spontaneously follow the buccal movement
of deciduous molars for about 60% of their movement.
When thinking about differences between several activa-
tion protocols for maxillary expansion, a recent systematic Fig. 11.1 Invisalign First optimized attachments for maxillary expansion.
review22 helps us to understand some outcomes comparing
slow maxillary expansion (SME) and RME; there is moder-
ate evidence showing that maxillary transverse diameters
increase signicantly within both groups in the short-
term,23 but SME protocol is more predictive of bodily upper
molar movement, while the RME protocol produces more
tipping movement in the molar region.24
RME uses heavier interrupted forces to maximize ortho-
F F
pedic effects, and slow palatal expansion uses lighter con-
tinuous forces to move teeth at rates purported to be more
physiologic.11 Aligners use intermittent light forces to move
teeth, and intermittent forces are able to produce orthodon-
tic tooth movement with less cell damage in the periodon-
tium.25 Since it has been stated that light, continuous forces
seem to be perceived as intermittent forces by the periodon-
tium due to its viscoelastic nature,26 the expansion produced
by aligners could be described as SME. Fig. 11.2 Invisalign First maxillary expansion protocol staging.
A clear aligner maxillary expansion protocol has been
recently proposed (Invisalign First, Align Technology, Inc.,
San José, CA, USA). Aligners could overcome some of the lingual arch releasing light continuous forces for dental ex-
limitations presented by palatal expander particularly in pansion also will open the midpalatal suture.28 Therefore, it
non-crossbite cases. With these appliances, it is possible to can be assumed that intermittent forces released by aligners
control the movement of all the teeth in the maxillary arch, can be sufcient in children up to 8 or 9 years of age to act
aiming to produce an initial alignment and leveling while on the transversal dimension of the maxilla.
expanding the arch. Aligners can be really helpful in con- A recent clinical trial conducted at the University of To-
trolling maxillary rst molars not only on the frontal plane rino (Torino, Italy) in which clear aligners and RPE effects
but on the horizontal and sagittal planes, too, avoiding all in patients with maxillary constriction were measured on
the issues mentioned earlier in relation to potential peri- digital models, suggests that:
odontal problems. Furthermore, aligners can control the n A signicant increase in palatal volume, so as in the
expansion limited to the anterior region of the arch to gen-
other parameters, has been proved for both treatments.
erate adequate space for the spontaneous alignment of the n The RPE slightly outperform clear aligners considering
permanent upper lateral incisors prior to complete eruption.
all the parameters tested.
Because of the short clinical crowns of deciduous teeth, n The compliance and the clinical condition could affect
specic attachment shapes were designed to increase aligner
the potential results achievable by the clear aligners.
retention and control the tipping movement to obtain torque
compensation and avoid a deepening of the curve of Wilson The Clear Aligners demonstrated a reasonable ability to
(Fig. 11.1). achieve palatal expansion. Since the materials have im-
Regarding staging, two options are available at the moment: proved over the last years, so as the academic efforts to bet-
(1) Permanent molars (if required by the treatment plan) will ter understand the potential of CAT, substantial advances
be moved buccally, using the rest of the arch as anchorage, and can be expected in the near future.58
only once they have reached their nal position will the decidu-
ous molars and canines be moved buccally using permanent
molars and incisors as anchorage units. (2) Permanent molars Expansion Case Reports
and deciduous teeth are moved buccally in a simultaneous
manner (Fig. 11.2). Because of the geometry of the aligners, For the following case reports, three-dimensional (3D)
their distal portions are not stiff enough to support a predict- evaluation of upper arch and palate morphology was per-
able buccal movement of so many teeth at the same time, mak- formed according to a previous study by Bizzarro et al.29
ing this staging not the rst-line treatment option. The upper arches were scanned using a 3D scanner (iTero
Timing is another important factor to be considered. The Element). The 3D data were imported to a reverse model-
best timing to expand maxillary arch is during the early ing software package called Geomagic Studio (3D Systems,
mixed dentition, before upper permanent lateral incisor Inc).30 Intermolar, intersecond deciduous molar, and inter-
eruption and after the permanent molars are fully erupted canine transverse widths at the cusps and gingival levels
and in occlusion. This timing is favorable as the midpalatal were measured (Fig. 11.3), as well as anterior and poste-
suture is more immature.27 In young children, up to age 8 or rior palatal depths at the cusp level, palatal surface area
9 years, little force is needed. Up to that age, a transpalatal (Fig. 11.4), and volume (Fig. 11.5).

CC
CG
cC
cG
MC
MG
Fig. 11.3 CG intercanine widths assessed at gingival level, CC interca-
nine widths assessed at cusp level, cG inter-E widths assessed at gingi-
val level, cC inter-E widths assessed at cusp level, MG intermolar widths
assessed at gingival level, MC intermolar widths assessed at cusp level.
GP
DP
MSP
Fig. 11.4 The anterior and posterior depth of the palatal vault is de-
ned as the vertical distance from the contact line between the cusp of
the right and left canine and mesiopalatal cusp tips of the right and left
rst molars to the palatal vault, respectively. The palatal volume was
dened by the median sagittal, distal, and gingival planes as boundar-
ies of the palate. The distal plane (DP) passed through two points at the
distal of the rst upper permanent molars. The gingival plane (GP) was
created by intersecting the distal and median sagittal planes (MSP)
through the center of incisive papilla, which is considered a stable
point structure.31 All planes were perpendicular to each other.
CASE STUDY 1
Consider an 8-year-old boy with upper central incisor pro-
trusion, mild upper anterior crowding, and palatal tipping
of deciduous teeth. Invisalign First was adopted, and se-
quential expansion of molars rst and then deciduous teeth
11 • Interceptive Orthodontics with Aligners 123
GP
Line 7
DP
Fig. 11.5 The palatal surface area was dened by the median sagittal
(MSP), distal (DP), and gingival (GP) planes as boundaries of the palate.
The distal plane (DP) passed through two points at the distal of the rst
upper permanent molars.
was planned within the ClinCheck, along with alignment
of central and lateral incisors. The patient was instructed to
change the aligners every week, and control examinations
were planned every 6 weeks. Pre- and postexpansion
scan screenshots are shown in Fig. 11.6. The expansion
phase lasted 8 months. The palatal volume increased from
3843.54 mm3 to 5330.89 mm3 due not only to the
vestibular dental tipping but also increased interarch
widths measured at both gingival and a cuspal levels.
Quantitative evaluations of intraarch widths, palatal areas,
and volumes for this case are summarized in Table 11.1 as
Case 1 reports.
CASE STUDY 2
Consider a 9-year-old girl with upper anterior crowding and
deep bite. Invisalign First was adopted, and sequential ex-
pansion of molars rst and then deciduous teeth was
planned within the ClinCheck, along with the alignment of
central and lateral incisors. The patient was instructed to
change the aligners every week and control examinations
were planned every 2 months. Pre- and postexpansion scan
screenshots are shown in Fig. 11.7. The expansion phase
lasted 6 months. The palatal volume increased from 4342.64
mm3 to 6948.68 mm3 due not only to the vestibular dental
tipping but also increased interarch widths measured at
both a gingival and a cuspal level. Quantitative evaluations
of intraarch widths, palatal areas, and volumes for this case
are summarized in Table 11.1 as Case 2 reports.
Class II Malocclusion
Class II malocclusion is the most frequent skeletal sagittal
disharmonies in the white population.32 Diagnosis using
124 Principles and Biomechanics of Aligner Treatment

B
Fig. 11.7 Case 2 pre- (A) and post (B) therapy scans of the maxillary
B arch.
Fig. 11.6 Case 1 pre- (A) and post (B) therapy scans of the maxillary
arch.

Table 11.1 Pre- and post-treatment volumetric and linear measurements obtained in the reported cases.
A mm2 V mm3 CG mm CC mm cG mm cC mm MG mm MC mm
Case 1 pre 1105.91 3843.54 22.6 29.1 28.2 32.2 32.6 36.8
Case 1 post 1316.57 5330.89 27.6 36.7 33.4 39.7 36 42.1
Case 2 pre 1111.67 4342.64 24.4 32.1 29.8 34.5 35.1 39.7
Case 2 post 1478.69 6948.68 26.3 37.5 32.9 39.5 35.4 42.1

A, Palatal surface area; CC, intercanine widths assessed at cusp level; cC, inter-E widths assessed at cusp level; CG, intercanine widths assessed at gingival level;
cG, inter-E widths assessed at gingival level; MC, intermolar widths assessed at cusp level; MG, intermolar widths assessed at gingival level; V, palatal volume.

cephalometric tracings may highlight different dental
or skeletal components of class II malocclusion: upper inci-
sor proclination, lower incisor retroclination, mandibular
retrognathia, ipomandibulia, maxillary protrusion, iper-
maxillia, or different combinations of these components.
Mandible retrusion has been found to be the main factor in
most basal class II malocclusions.33,34 One orthopedic ap-
proach developed to treat mandibular skeletal retrusion in
growing patients is the forward repositioning of the man-
dible,35,36 even if a general consensus about the efcacy and
 11 • Interceptive Orthodontics with Aligners 125

efciency of this approach is still missing36 37 (probably for

inconsistent evidence of homogeneous interventions,37 38
wide variations in individual responsiveness,39 and different
timings in orthodontic intervention9), and undergoing
mandibular advancement in specic growth phases has
been reported to have a key role in successful treatment
outcomes.
Several studies have shown that the optimal biologic tim-
ing for the achievement of skeletal effects is the circumpu-
bertal growth period,40-43 when the greater mandibular
growth response occurs, so that treatment can start in the
early mixed dentition.41 The pubertal peak can be identied
by several growth indicators, including skeletal maturation
(cervical vertebrae maturation method, hand-wrist radio-
graphs), dental maturation, and chronologic age,42 44 45
and more recently the reliability of gingival crevicular uid A
(GCF) biomarkers specic for growth spurt characterization
has been under investigation.46 47
A morphologic predictive factor in successful mandible
repositioning with functional appliances is the pretreat-
ment mandibular angle (Co-Go-Me angle ,125.5 degrees).
As shown by Franchi and Baccetti39 as well as previous
animal and human studies,43 a small mandibular angle is
correlated with an enhanced responsiveness to mandibular
forward positioning, and vice versa.
The usual main limitation for removable functional ap-
pliances is patient noncompliance, rated by O’Brien as
18% in children, raising to 30% in adolescence.48 Non-
compliance can depend on bulky and invasive devices, B
difculties in speech, impact on social life, esthetics, and
public perception, not precise and predicted orthodontic Fig. 11.8 Runner appliance. Upper arch aligner (A) and lower arch aligner
tooth movements. To overcome these limitations, aligner (B). (From Arreghini A, et al. Class II treatment with the Runner in adolescent
patients: combining twin block efciency with aligner aesthetics. J World Fed
therapy may be considered a good, reliable, and comfort- Orthod. 2014;3[2]:71–79.)
able alternative. The use of the compliance indicators
embedded in the aligner represents a good attempt to
monitor patient compliance.49 More recently articial in-
telligence has been introduced in the orthodontic eld to
remote monitor patient compliance (Dental Monitoring,
Paris, France).
Functional treatment of growing class II patients during
their pubertal growth spurt can bring about signicant skel-
etal and dentoalveolar modications. According to Cozza et
al.,37 the twin block is the most efcient removable func-
tional appliance because it can stimulate 0.23 mm/month
of mandibular growth (for a total of 3.4 mm in 13 months),
followed by the Bionator (0.17 mm/month, total 2.8 mm in
12 months), and then the Frankel II (0.09 mm/month, total
2.8 mm in 18 months). The mechanism behind the Clark
twin block is based on the presence of an inclined plane,
which pushes the mandible forward, liberates the arches,
and redirects the occlusal forces to drive the mandibular
Fig. 11.9 Intraoral Invisalign First with mandibular advancement
advancement and arrest maxillary growth.50 feature.
Two companies (Align Technology Inc, San José, CA,
USA and Leone SPA Company, Sesto Fiorentino, Firenze,
Italy) have developed a new feature within aligner appli-
ances,51 combining the twin block and the aligner advan-
tages to stimulate growth of the mandible while aligning efciency of the twin block with the esthetics and low bulk
and leveling in growing patients. of clear aligners.52
The Leone company appliance called Runner (Fig. 11.8) The Align Technology company appliance is the Invis-
consists of a series of clear aligners with incorporated align aligner incorporating lateral wings (Figs. 11.9 and
occlusal blocks for mandibular advancement, joining the 11.10) engaging the mandible in a forward position.
126 Principles and Biomechanics of Aligner Treatment
A on growing patients both at CVM2 and CVM3. When
B emotional and social domains of the oral health–related
Fig. 11.10 Invisalign First with mandibular advancement feature. Upper
arch aligner (A) and lower arch aligner (B)
The mandibular advancement system is divided into three
clinical phases:
n Pre–mandibular advancement phase: the occlusal locks,
which prevent expression of mandibular growth, are
removed (correction of overbite, maxillary molar rota-
tions, and overjet)
n Mandibular advancement phase: 2-mm advancement every
eight aligners is performed
n Transition phase (or stabilization phase): maintains the
class II correction
Mandibular advancement can be reached only if other
eventual occlusal features have been modified (i.e., max-
illary molar derotation, dentoalveolar expansion of the
upper arch, deep bite and consequent leveling of the
curve of Spee, and retroclination of the incisors), so that
a prior preparation phase is required before starting
mandibular advancement. While the Runner appliance,
the twin block, and other functional appliances are built
with a single jump repositioning the mandible, the In-
visalign appliance is designed to obtain progressive ad-
vancement of the mandible with steps of 2 mm every
eight aligners. The progressive advancement of the
mandible has been demonstrated to be more effective
in producing skeletal outcomes both in animal53 54 and
human studies.55
At the end of treatment, mandibular advancement is
maintained by arch coordination and anterior interference
removal.
In class II treatments, assessment of skeletal age and
auxologic potential and predicting the direction of man-
dibular growth constitute strategic factors determining
treatment efcacy.
Concerning the importance of right timing to choose
the beginning of the interceptive class II correction
phase, recent perspective-controlled studies by the Uni-
versity of Turin (Italy) aim to compare dental and skel-
etal effects of 12 months of therapy with the mandibu-
lar advancement feature by Invisalign, when performed
used in the pre-pubertal stage of growth, Invisalign®
aligners, with Mandibular Advancement feature, have
mainly dentoalveolar effects in the short-term period.
When used in the pubertal growth phase, the short-
term effects of Mandibular Advancement feature are
dento-skeletal, with an annual rate of change compa-
rable to what has been previously described for the Twin
Block appliance.59
According to the existent literature, early treatment of
class II division I malocclusion should be provided only to
reduce the risk of incisal trauma.56 Additionally, dental in-
juries have been reported to have a negative impact on the
quality of life. Since this impact is considerable especially
for children having active lifestyles, parents will consider
that early orthodontic treatment is worth the nancial
costs and burden of care.57
Furthermore, there are young patients for whom the
malocclusion is esthetically distressing, and they are bullied
for this reason. The use of aligners provided for functional
and orthopedic adjuncts can have a positive impact on the
self-esteem of those patients even during the orthodontic
treatment, providing excellent orthodontic care for such
children.
Mandibular Advancement
Case Reports
CASE STUDY 3
Consider a 9-year-old girl, in mixed dentition, with
molar class II relationship, deep bite, proclined upper
incisors, and retruded mandible. Cephalometric analysis
shows a moderate skeletal class II malocclusion, with
an ANB angle value of 5 degrees, and Wits value of
7 mm (Fig. 11.11–11.13). According to Baccetti et al.,42
the patient was in a pubertal growth spurt, which is why
the treatment plan was designed to focus on mandibular
advancement. An Invisalign Teen treatment with
the mandibular advancement feature was performed
(Fig. 11.14).
The appliance was prescribed to determine an
advancement of the mandible together with deep bite
correction. The ClinCheck plan forecasted 2 mm of
advancement every eight stages, and aligners were
changed every week. After 6 months of treatment, a
bilateral class I molar relationship was achieved
(Figs. 11.15–11.16 and 11.17), and dentoskeletal im-
provements were achieved.
 11 • Interceptive Orthodontics with Aligners 127

Fig. 11.11 Case 3 Initial extraoral pictures.

Fig. 11.12 Case 3 initial intraoral pictures.

128 Principles and Biomechanics of Aligner Treatment

Fig. 11.13 Case 3 initial radiographic records.

Fig. 11.14 Case 3 sagittal view of ClinCheck.

Fig. 11.15 Case 3 nal clinical records.


Fig. 11.16
CASE STUDY 4
Consider a 10-year-old girl in mixed dentition with psycho-
logical issues, reporting bullying episodes due to the protru-
sion of upper incisors and the retrusion of the mandible.
The clinical examination showed a molar class II relation-
ship, severe deep bite, skeletal class II with ANB angle of
6 degrees, and Wits value of 5 mm (Fig. 11.18–11.20).
11 • Interceptive Orthodontics with Aligners 129
Analyzing the cervical vertebrae maturation on the lateral
x-ray, the patient resulted in a CVM3 phase, according to
Baccetti et al,42 and is therefore in a phase of accelerated
condylar growth. Since the girl was psychologically stressed
because of her bad-looking teeth, an additional stress due
to a bulky appliance would not have been the best choice.
Thus Invisalign Teen with the mandibular advancement
feature was adopted (Fig. 11.21).
130 Principles and Biomechanics of Aligner Treatment

Initial 12 months later

Wits = 7 mm Wits = 3 mm
SNB = 72° SNB = 74°
Co-Gn = 92 mm Co-Gn = 98 mm
U1^PP = 127° U1^PP = 107°

Fig. 11.17 Case 3 changes of mandibular prole and cephalometric values before and after therapy.

Fig. 11.18 Case 4 initial clinical and radiographic records.

 11 • Interceptive Orthodontics with Aligners 131

Fig. 11.19
132 Principles and Biomechanics of Aligner Treatment

Fig. 11.20

In 6 months of treatment, an important correction of Conclusions

the molar relationship and of the proclination of upper
incisors was obtained. During the mandibular advance-
ment phase treatment, improvement of the facial prole
was the most important motivational factor acting on
the patient’s and the parents’ compliance (Figs. 11.22–23
and 11.24).
The timing of orthodontic treatment has long been debated.
Among the proposed benets of early intervention are the
potential for improved response to growth modication.
Transversal alterations are frequently seen in general dental
practices. Aligners can control the expansion limited to the

Fig. 11.21 Case 4 sagittal view of ClinCheck and superimposition of initial ClinCheck with final ClinCheck
(occlusal view).

anterior region of the arch to generate adequate space for
the spontaneous alignment of the permanent upper lateral
incisors prior to complete eruption, helping the future arch
development. Researchers in the elds are recommended to
dene possibilities and limitations of the approach.
Routine early treatment for class II division I malocclu-
sion with retrognathic mandible should not be provided ac-
cording to the existing quality of evidence. However, there
are patients for whom the malocclusion is so esthetically
Fig. 11.22 Case 4 nal clinical records and changes of mandibular prole.
11 • Interceptive Orthodontics with Aligners 133
distressing and/or who are bullied signicantly because of it
that treatment is certainly indicated. In those cases, the use
of a discrete and noninvasive appliance like an aligner with
mandibular forward repositioning wings or planes could
represent an excellent possibility. Another group of patients
for whom the early treatment could be indicated is repre-
sented by children with active sports schedules and life-
styles, putting them at risk of incisal trauma because of
their large overjet.
134 Principles and Biomechanics of Aligner Treatment

Fig. 11.23

Initial 12 months later

Wits = 5 mm Wits = 1 mm
SNB = 71° SNB = 74°
Co-Gn = 91 mm Co-Gn = 96 mm
U1^PP = 137° U1^PP = 119°

Fig. 11.24 Case 4 cephalometric values before and after therapy.


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28. De Clerck HJ, Proft WR. Growth modication of the face: a current
perspective with emphasis on class III treatment. Am J Orthod Dento-
facial Orthop. 2015;148(1):37-46.
29. Bizzarro M, Generali C, Maietta S, et al. Association between 3D
palatal morphology and upper arch dimensions in buccally
displaced maxillary canines early in mixed dentition. Eur J Orthod.
2018;40(6):592-596.
30. Martorelli M, Maietta S, Gloria A, et al. Design and analysis of 3D
customized models of a human mandible. Procedia CIRP.
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31. Shah M, Verma AK, Chaturvedi S. A comparative study to evaluate the
vertical position of maxillary central incisor and canine in relation to
incisive papilla line. J Forensic Dent Sci. 2014;6(2):92-96.
32. Alhammadi MS, Halboub E, Fayed MS, et al. Global distribution of
malocclusion traits: a systematic review. Dental Press J Orthod. 2018;
23(6):40.e1-40.e10.
33. Li P, Feng J, Shen G, et al. Severe class II division 1 malocclusion in an
adolescent patient, treated with a novel sagittal-guidance twin-block
appliance. Am J Orthod Dentofacial Orthop. 2016;150(1):153-166.
34. McNamara Jr JA. Components of class II malocclusion in children
8–10 years of age. Angle Orthod. 1981;51(3):177-202.
35. Marsico E, Gatto E, Burrascano M, et al. Effectiveness of orthodontic
treatment with functional appliances on mandibular growth in the
short term. Am J Orthod Dentofacial Orthop. 2011;139(1):24-36.
36. Chen JY, Will LA, Niederman R. Analysis of efcacy of functional
appliances on mandibular growth. Am J Orthod Dentofacial Orthop.
2002;122(5):470-476.
37. Cozza P, Baccetti T, Franchi L, et al. Mandibular changes produced by
functional appliances in class II malocclusion: a systematic review.
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e1-6.
38. Antonarakis GS, Kiliaridis S. Short-term anteroposterior treatment
effects of functional appliances and extraoral traction on class II
malocclusion: a meta-analysis. Angle Orthod. 2007;77(5):907-914.
39. Franchi L, Baccetti T. Prediction of individual mandibular changes
induced by functional jaw orthopedics followed by xed appliances in
class II patients. Angle Orthod. 2006;76(6):950-954.
40. Perinetti G, Contardo L, Primozic J. Diagnostic accuracy of the cervical
vertebral maturation method. Eur J Orthod. 2018;40(4):453-454.
41. McNamara JA, Brudon WL, Kokich VG. Orthodontics and Dentofacial
Orthopedics. Needham Press; 2001.
42. Baccetti T, Franchi L, McNamara Jr JA. The cervical vertebral matu-
ration (CVM) method for the assessment of optimal treatment timing
in dentofacial orthopedics. Semin Orthod. 2005;11(3):119-129.
43. Petrovic A, Stutzmann J, Lavergne J. Mechanism of craniofacial
growth and modus operandi of functional appliances: a cell-level
and cybernetic approach to orthodontic decision making. Craniofacial
growth theory and orthodontic treatment. Monograph. 1990;23:
13-74.
44. Beit P, Peltomäki T, Schätzle M, et al. Evaluating the agreement
of skeletal age assessment based on hand-wrist and cervical ver-
tebrae radiography. Am J Orthod Dentofacial Orthop. 2013;144(6):
838-847.
45. Franchi L, Baccetti T, McNamara Jr JA. Mandibular growth as
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46. Perinetti G, Baccetti T, Contardo L, et al. Gingival crevicular uid
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skeletal maturation. Orthod Craniofac Res. 2011;14(1):44-50.
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47. de Aguiar MC, Perinetti G, Capelli Jr J. The gingival crevicular uid as a
source of biomarkers to enhance efciency of orthodontic and functional
treatment of growing patients. Biomed Res Int. 2017;2017:3257235.
48. O’Brien K, Wright J, Conboy F, et al. Early treatment for class II
division 1 malocclusion with the twin-block appliance: a multi-center,
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2009;135(5):573-579.
49. Tuncay OC, Bowman SJ, Nicozisis JL, et al. Effectiveness of a compli-
ance indicator for clear aligners. J Clin Orthod. 2009;43(4):263-268.
50. Clark WJ. The twin block technique. A functional orthopedic appli-
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51. Rossini G, Parrini S, Castroorio T, et al. Efcacy of clear aligners in
controlling orthodontic tooth movement: a systematic review. Angle
Orthod. 2014;85(5):881-889.
52. Arreghini A, Carletti I, Ceccarelli MC, et al. Class II treatment
with the Runner in adolescent patients: combining twin block
efficiency with aligner aesthetics. J World Fed Orthod. 2014;
3(2):e71-e79.
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step advancement with the functional mandibular advancer in class
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2021 Jun; 22(2):119-124.
 12 The Hybrid Approach in
Class II Malocclusions
Treatment
FRANCESCO GARINO, TOMMASO CASTROFLORIO, and SIMONE PARRINI
Introduction
Several protocols have been proposed for treatment of class
II malocclusions. In nonextraction protocols, maxillary
molar distalization can be used to correct molar relation-
ships in patients with maxillary dentoalveolar protrusion
and minor skeletal discrepancies.1
The upper molars can be distalized by means of extraoral
or intraoral forces. In recent years, several techniues have
been developed to reduce the dependence on patient com-
pliance, such as intraoral appliances with and without
skeletal anchorae. owever, even these devices can pro-
duce undesirable tippin of the maxillary molars andor
loss of anterior anchorae durin distalization.
In the last decades, increasin numbers of adult patients
have souht orthodontic treatment and expressed a desire
for esthetic and comfortable alternatives to conventional
xed appliances. lear aliner therapy T was intro-
duced to answer this reuest.
In a review by ossini et al. it has been stated that maxil-
lary molar distalization up to . mm is one of the most
predictable movements with T.  This hih predictability
was obtained throuh combination of stain, the use of
proper attachment conuration, and full-day class II elas-
tics . in, . oz see hapters about lass II treatment
and see hapters  and . These results conrm what ev-
ery orthodontist knows Treatment success reuires techni-
cal knowlede from the orthodontist as well as the coopera-
tion of the patient. lass II treatments with T reuire
mean treatment times of 1 to  months durin which
class II elastics need to be used all day from treatment be-
innin until class I canine relationship has been estab-
lished.  orrective devices should be comfortable, provide
rapid and effective treatment, and favor patient compliance
with orthodontic treatment. lear aliners are comfortable
and aesthetically acceptable as already discussed in the
previous chapters,  and reuire stron patient compliance
since they are removable. The existin literature showed
that the mean duration of obectively measured wear was
considerably lower than stipulated wear time amon all re-
movable appliances. urthermore, compliance was found
to be better in the early staes of treatment.1
Startin from these premises, the possible combined use
of aliners and other orthodontic devices aimed to optimize
patient adherence to therapy reducin the time reuired to
wear class II elastics has been proposed. This kind of com-
bined approach has been named hybridization of aliner
therapy. mon others, temporary anchorae devices
bone-borne hybrid approach see hapter about minis-
crews and tooth-borne distalization devices are the most
popular hybridization approaches in T.
The application of forces in such distalizin appliances
could be from buccal reion, palatal reion, or both, and
they could be based on slidin mechanics or be friction free
e.., in the endulum appliance.
Tooth-Borne Hybrid Approach
With Distalizing Device
arious types of molar distalization appliances are available
and presented in the orthodontic literature, such as the
endulum device, the istal et, and the arriere otion 
ppliance  enry Schein rthodontics, arlsbad,
, S.
These appliances are considered easy to install and can
promote distal movement of the maxillary molars without
the effect of maxillary orthopedic restriction.11 owever,
most of these intraoral devices show undesirable reciprocal
anchorae loss in the premolars and incisors durin distal
molar movement.1 urthermore, molar tippin is fre-
uently observed in most of the cases.
The istal et appliance is composed of two bilateral
tubes connected to a ance appliance.  bayonet wire is
inserted into the linual sheath of the rst molar bands. n
the tube there is a stainless steel coil sprin and a clamp.
The clamp can slide toward the molar and be tihtened to
compress the coil. The force exerted by the sprin beins at
1  and decreases as space is opened.1
The endulum appliance was introduced by ilers in
11 and is still one of the most used distalizin de-
vices.1 It is a xed appliance composed of a plastic pad–
contacted palatal ruae. The distalizin force is produced by
beta-titanium sprins that extend from the palatal acrylic
and t into linual sheaths on the molar tube, which ives
reater control of these teeth.1
oth the istal et and endulum appliances produce an
increase in vertical dimension due to a backward rotation
of the mandible.1-1 These vertical chanes comprise
a sliht openin of the mandibular plane anle about
1 deree and an increase in lower anterior facial heiht
.–. mm.1 hosh and anda reported that the in-
crease in lower anterior facial heiht was sinicantly
reater in patients with hiher pretreatment mandibular
plane anles. The increased lower facial heiht and man-
dibular plane anle could have resulted from drivin the
137
138 Principles and Biomechanics of Aligner Treatment
molars back into the “wede.” These results suest that
the endulum may be contraindicated in patients with
excessive lower facial heiht andor minimal overbite.1
Similar results were reported for the istal et appliance.1
The maxillary molar distalization obtained with those
appliances is characterized by a reat amount of molar
distal tippin in averae .1 derees.1
hereas the istal et produces a labial tippin of the
upper incisors as a result of the uncontrolled counterforce
actin on the premaxillae, the endulum appliance showed
a more controlled inclination of the upper incisors with a
mild crown buccal tippin.
 consists of two riid bars bonded bilaterally to the
maxillary canines and rst molars. The canine pad with a
built-in mesial hook used for placement of intermaxillary
elastics is bonded to the anterior third of the clinical crown.
osteriorly, the molded pad with a ball-and-socket oint is
bonded to the rst molar at the center of its clinical crown
to facilitate molar derotation and distalization.1-
The activation of the appliance is obtained by the use of
two types of elastics the rst one bein . in,  oz the
second one .1 in,  oz, to be used from the second month
of treatment until the molar and canine class I relation-
ships are established. lastics should be worn  hours per
day, chanin elastics three times per day.
The principle of this appliance is similar to a cantilever-
based xed appliance previously shown by anda. The
author described that system as an effective way to correct
molar class II in nonrowin patients. n active cantilever
with information of molar tipback was applied at the upper
arch, while in the lower arch the author used a multi-
bracket xed appliance and class II elastics. The undesired
effects of class II elastics were controlled by the xed appli-
ance in lower arch and by the activation of the cantilever in
upper arch.
revious retrospective clinical studies demonstrated the
possibility of obtainin a maxillary molar distalization be-
tween 1. and .1 mm with the mean amount of molar
tippin not exceedin . derees when  was used in
combination with xed appliances as anchorae units on
the lower arch. urthermore the treatment time had a
mean duration of about  to  months.
There is a lack of hih-uality evidence supportin or
contrastin the use of . In another retrospective study
in which  effects were compared to other class II cor-
rection methods,  showed the same results obtained
with class II elastics in terms of molar distalization but in
less time.
ne clinically and statistically relevant effect of treat-
ment with  occurred in lower anterior facial heiht
that was associated with a sinicant increase in the
mandibular plane anle.
roclination of the lower incisors resultin from the class
II elastics mechanics was observed and resulted in a sini-
cant amount . derees.
ll the tooth-borne appliances mentioned earlier pro-
duce some side effects that need to be controlled durin the
hybrid aliner treatment. xcessive upper and lower incisor
proclination could be difcult to control with aliners. c-
cordin to ossini et al., buccolinual tippin and torue
control of upper incisors have a mean accuracy of about
 of the planned movement. The proclination of lower
incisors resultin from the use of  could be controlled
usin active aliners on the lower arch and applyin a lin-
ual radicular torue information on the lower incisors of
at least  derees.
nother side effect that can occur usin tooth-borne
distalization devices is the rotation of the occlusal plane
due to the increase of the vertical dimension.
hosravi et al. in their study about overbite manae-
ment with Invisalin aliners showed that overbite correc-
tion is mostly related to anterior teeth movement without
any sinicant posterior intrusion andor extrusion. s
described by avera et al. bite block effect of the aliner
causes an intrusive effect on posterior teeth of . mm. 
similar value . mm was described by antovani et al.
Therefore, only the .- to .-mm bite block effect should
be considered to counteract the increase of the vertical
dimension produced by tooth-borne distalization devices
averae increase – mm.
n the basis of these considerations, tooth-borne distal-
ization devices should be avoided in patients with excessive
lower facial heiht andor minimal overbite. linicians
should be aware of the existin evidence related to the lim-
ited control of posterior intrusion, overbite correction, and
buccolinual inclination provided by T.
Two clinical examples will be presented one in a teen
patient and the second in an adult patient.
Case eport 1
DIAGNOSTIC SUMMARY
 1-year-old female patient presented with molar class II
malocclusion, skeletal class II, normal diverence, protru-
sion of upper and lower incisors, and unerupted upper left
canine is. 1.1, 1., and 1..
The impaction was related to the mesialization of upper
left posterior teeth with a conseuent absolute lack of space
for the canine eruption. adioraphs conrmed the buccal
displacement of the impacted upper canine.
The patient’s main concern was lack of the upper left
canine.
The treatment plan was desined to obtain bodily distal
movements of upper molars, premolars, canines, and fron-
tal teeth to achieve a dental molar and canine class I, and
recover the proper space for  without extractions.
 endulum  appliance was bonded on the upper
arch to distalize maxillary molars i. 1..
nce the class I was overcorrected  months treatment,
the endulum appliance was debonded, and a new intra-
oral scan was made to start the aliner treatment. The aim
of this second phase was to close the remainin spaces in
the upper arch, to recover tooth  in the arch and to cor-
rect lower crowdin. The same day temporary thermo-
formed retainers were provided to the patient.
 set of  Invisalin aliners was produced to complete
the distalization movements on the upper arch and to cor-
rect the lower arch mild crowdin. liner chane was
planned every week. urin the aliner phase the patient
was educated to wear class II elastics . in, . oz
bilaterally to reinforce anterior anchorae while distalizin
premolars. To anchor class II elastics, buttons were bonded
 12 • The Hybrid Approach in Class II Malocclusions Treatment 139

Fig. 12.1 Case 1. Etraoral pictures before treatment.

on the lower rst molars, while aliner hooks were used on
the upper rst premolars reion.
nce enouh space was obtained, the upper left canine
was surically exposed with a vestibular ©ap, and a button
with stainless steel hook was bonded to the buccal surface
of the crown. The tooth was then moved distally rst with
class II elastics to recover a proper position on the saittal
plane i. 1..
hen  was close enouh to the occlusal plane, new
intraoral scans were performed to obtain a new set of 1
aliners to finalize the case is. 1., 1., and 1..
The total treatment duration was  months.
140 Principles and Biomechanics of Aligner Treatment

Fig. 12.2 Case 1. Intraoral pictures before treatment.

A B

Fig. 12.3 Case 1. A Panoramic ray before treatment. B ateral ray before treatment.
 12 • The Hybrid Approach in Class II Malocclusions Treatment 141

Fig. 12.4 Case 1. Intraoral pictures at end of sagittal rst phase.

Fig. 12.5 Case 1. Intraoral pictures before additional aligner stage.

142 Principles and Biomechanics of Aligner Treatment

Fig. 12.6 Case 1. Etraoral pictures at end of treatment.

Fig. 12.7 Case 1. Intraoral pictures at end of treatment.

 12 • The Hybrid Approach in Class II Malocclusions Treatment 143

A B

Fig. 12.8 Case 1 A Panoramic ray at end of treatment. B ateral ray at end of treatment.

Case eport 2
DIAGNOSTIC SUMMARY
 -year-old male patient presented with molar class II
malocclusion, skeletal class II, low mandibular plane anle,
overbite, and crowdin on both upper and lower arches
is. 1., 1.1, and 1.11.
The patient’s main concern was the excessive upper canine
buccal displacement and proclination of upper incisors.
The treatment plan was made to obtain bodily distal
movements of upper molars, premolars, and canines to
achieve a dental molar and canine class I, center midlines,
and correct crowdin on both arches.
  was bonded in the upper arch on both sides to
correct saittal relationship on molars, bicuspids, and ca-
nines i. 1.1.
In the meantime, the lower arch treatment started with a
rst set of  aliners to correct lower crowdin.  buccal
tube was bonded on lower rst molars to allow activation of
both  throuh the use, for the rst month, of . in,
 oz elastic placed from the mesial hook of the  to the
mesial hook of the lower buccal tubes. rom the second
month until class I molar and canine resulted, the patient
used a .1 in,  oz elastic with elastic chanes three times
a day. liners were instructed to be chaned every  weeks
at that stae.
nce the class I was obtained on both sides  months
treatment, the  was debonded, and a new intra-
oral scan was made of the aliner treatment i. 1.1.
The aim of this second phase was to close the remain-
in spaces in the upper arch created durin saittal
correction on both sides and to complete crowdin cor-
rection in the lower arch. Throuh the same scan and a
three-dimensional printin in-office procedure, one
temporary thermoformed retainer was provided to the
patient who was instructed to wear it day and niht.

Fig. 12.9 Case . Etraoral pictures before treatment.

144 Principles and Biomechanics of Aligner Treatment

Fig. 12.10 Case . Intraoral pictures before treatment.

A B

Fig. 12.11 Case . A Panoramic ray before treatment. B ateral ray before treatment.
 12 • The Hybrid Approach in Class II Malocclusions Treatment 145

Fig. 12.12 Case . Intraoral pictures before sagittal rst phase.

Fig. 12.13 Case . Intraoral pictures before additional aligner stage.

146 Principles and Biomechanics of Aligner Treatment

 set of 1 Invisalin aliners was produced to perform
space closure in the upper arch and to correct the lower
arch mild crowdin. liner chane was planned every
week.
fter 1 months of treatment, class I canine and molar
resulted on both sides, midlines centered, and deep bite
improved such as upper and lower arch forms. Third
molars present, the patient is currently in retention with
vacuum-type retainers that are used all nihts.
urin the retention period, the patient will be followed
up to evaluate third molars is. 1.1, 1.1, and
1.1.

Fig. 12.14 Case . Etraoral pictures at end of treatment.

Fig. 12.15 Case . Intraoral pictures at end of treatment.

 12 • The Hybrid Approach in Class II Malocclusions Treatment 147

Fig. 12.15, co’

B
Fig. 12.16 Case . A Panoramic ray at end of treatment. B ateral ray at end of treatment.

References
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. ossini , arrini S. ereibus , et al. ontrollin orthodontic tooth
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148 Principles and Biomechanics of Aligner Treatment
. arino , astro©orio T, aher S, et al. ffectiveness of composite
attachments in controllin upper-molar movement with aliners.
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. ichter , anda S, Sinha , et al. ffect of behavior modica-
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. ombardo , olonna , arlucci , et al. lass II subdivision
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. osvall , ields , iuchkovski , et al. ttractiveness, accept-
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1. Shah . ompliance with removable orthodontic appliances. Evid
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1. ilers . The pendulum appliance for class II noncompliance therapy.
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1. roft , ields , Sarver . Contemporary Orthodontics. St. ouis,
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1. arure S, atil , eddy S, et al. The effectiveness of pendulum,
-loop, and distal et distalization techniues in rowin children
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1. yloff , arendeliler , lar , et al. istal molar movement
usin the pendulum appliance. art  the effects of maxillary
molar root uprihtin bends. Angle Orthod. 11-.
1. haués-sensi , alra . ffects of the pendulum appliance on the
dentofacial complex. J Clin Orthod. 1-.
1. yloff , arendeliler . istal molar movement usin the
pendulum appliance. art 1 clinical and radioloical evaluation.
Angle Orthod. 1-.
. hosh , anda S. valuation of an intraoral maxillary molar
distalization techniue. Am J Orthod Dentofacial Orthop. 111
-.
1. arrière .  new class II distalizer. J Clinic Orthod. 
-1.
. artel . The arriere distalizer simple and efcient. Int J Orthod
Milauee. 1-.
. odríuez . nilateral application of the arriere distalizer.
J Clin Orthod. 111-1.
. Sandifer , nlish , olville , et al. Treatment effects of
the arrière distalizer usin linual arch and full xed appliances.
J orld ed Orthod. 1e-e.
. anda . Biomechanics in Clinical Orthodontics.  Saunders 1.
. in , an , uo , et al. valuatin the treatment effectiveness and
efciency of arriere distalizer a cephalometric and study model
comparison of class II appliances. Prog Orthod. 11.
. im-erman , camara r , ints , et al. Treatment effects
of the arriere otion  ppliance for the correction of class II in
adolescents. Angle Orthod. 1-.
. hosravi , ohanim , uoel , et al. anaement of overbite
with the Invisalin appliance. Am J Orthod Dentofacial Orthop.
1111-.
. antovani , arrini S, oda , et al. icro computed tomoraphy
evaluation of Invisalin aliner thickness homoeneity. Angle Or
thod 1. doi1.1-.1. pub ahead of print.
. inziner S, ehrbein , ross , et al. olar distalization with
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of unerupted canines and premolars. Am J Orthod Dentofacial Orthop.
1-1.
 13 Aligners and Impacted
Canines
EDOARDO MANTOVANI, DAVID COUCHAT,
TOMMASO CASTROFLORIO
Introduction
Except for the third molars, the impaction of the upper ca-
nine is the most common in the permanent dentition, and
its recovery is nearly always recommended. The impor-
tance of canines, both from a functional and an aesthetic
point of view, is crucial to set a proper occlusion. Further-
more, possible adverse sequelae of canine impaction1 can
be as follows:
n iration of the neihborin teeth and loss of arch
lenth
n External root resorption of the neihborin teeth
n entierous cyst formation
n nfections related to partial eruption
The prevalence of upper canine impaction is ranin
between . and ., dependin on the population, ae,
sex, and ethnicity.-
The impacted maxillary canines are more common in
white populations and in female patients, with a male to
female ratio of approximately 1:.
mpactions are unilateral in the maority of cases, and
the occurrence on the palatal side is three times hiher
than on the labial side.,
ome systemic endocrine or infectious diseases are re-
lated with failed eruption of one or more teeth Fi. 1.1.1
They act as predisposin factors but always in conunction
with a local patholoic condition, such as11:
n upernumerary teeth
n dontomas
n ental anomalies
n ysts
n revious trauma
n Early extractions
n nylosis
n left lip and palate
These factors can be associated with impactions of every
tooth and are usually related to incisors or premolars.
Therefore, other causes can be identied reardin impacted
canines. ince impacted upper canines have been diverted
or are anulated aberrantly durin development, it has
been assumed that eruption of the canine is stronly inu-
enced by environmental factors.1 1
The maxillary canine has the lonest path of eruption,
and a lon time period is needed. This could explain the
hiher percentae of inclusion compared to other teeth.
The upper canine beins its development from the supe-
rior part of the maxilla. t ae  years, the crown is located
in correspondence of the apex of deciduous canine, mesi-
ally inclined.1 hen the permanent incisors are erupted,
the close relationship between the crown of the canine and
the distal aspect of the root of lateral incisor is particularly
important.1 ince the upper cuspid is one of the last teeth
to reach its position, the lac of space in the arch can have
a reat inuence on the prevalence of impactions, espe-
cially reardin the labial ones.1
The studies that have investiated palatal impactions
pointed out the increased incidence of missin or pe-
shaped laterals.11,1 This leads to the formation of two
theories: the enetic theory and the uidance theory.,,1
oth theories share the belief that certain enetic features
occur in association with the palatal displacement of
maxillary canines. The riht side of any patient is eneti-
cally identical to the left side. ince many studies indicated
 to  preponderance of unilateral canine impac-
tion, it is reasonable to state that local factors are the
prevailin elements.1
ilberman demonstrated that anomalies of the lateral
incisors in patients with palatally displaced maxillary ca-
nine  teeth were found to be four times that of the
eneral population.1 The canine impaction has been re-
lated with abnormalities reardin the shape and lenth
of the root of the lateral incisor rather than its aenesis
Fi. 1..
owever, missin, small, and pe-shaped lateral incisors
are three varieties of expression of a sinle enetic factor. 
pe-shaped or small lateral incisor on one side of the mouth
and a missin on the other can be frequently seen Fi. 1..
ccordin to the uidance theory of canine impaction,
these factors create a enetically determined environment
in which the developin canine is deprived of its uidance,
thus inuencin it to adopt an abnormal eruption path.
Early Diagnosis and Treatment
 tooth is impacted when it fails to erupt into the dental
arch within the expected developmental window. Therefore,
an early dianosis is crucial to reduce the consequent is-
sues. alpation of the labial fornix to assess the crown of
the eruptin canine is the rst clinical attempt needed to
identify a possible impaction. n case of a well-mared
prominence absence in the late mixed dentition, orthopan-
tomoraphy  is mandatory Fi. 1..1
The early identication sins on radioraphs of an ab-
normal pathway of eruption is needed to prevent canine
retention and maxillary incisor root resorption.
149
150 Principles and Biomechanics of Aligner Treatment

C D

Fig. 13.1 (A–E) Early deciduous teeth extraction leads to loss of space and canine impaction.

The deciduous canine extraction is recommended when n The position sector s in the frontal view
limited or absent resorption of its root can be detected, in n etween the midline and the axis of the 1

class  uncrowded malocclusions.1, n etween the axis of 1 and 

Ericson and urol,1 to evaluate the need of primary ca- n etween the axis of  and 

nine extraction and its corrective effect, determined a
method for detection of the permanent canines, based on
the followin Fi 1.:
n The anle of the canine and the midline axis a
n The distance from the cusp tip to the occlusal line d
The success rate of early extractions will vary dependin
on the position of the permanent canine on . f the
crown of the permanent canine is distal to lateral incisor
root axis, the primary canine extraction normalied the
eruptin position of the permanent canine in 1 of
the cases. n contrast, the success rate decreased to  if
 13 • Aligners and Impacted Canines 151

B C

Fig. 13.2 (A–C) mall sie lateral incisors and impacted cuspids.

Fig. 13.3 (A) issing lateral incisors and (B) ilateral cuspid impaction.
152 Principles and Biomechanics of Aligner Treatment

A B

Fig. 13.4 (A–C) Bac of right canine prominence in late mixeddentition patient.

Fig. 13.5 (A B) The orthopantomography refers to the patient in ig. . Ericson and urol canine impaction analysis.
 13 • Aligners and Impacted Canines 153

91% 64%

Fig. 13.6 uccess rate of early deciduous canine extraction (from Ericson
and urol).

the permanent canine crown were mesial to the midline of

the lateral incisor root Fi. 1..
onetti et al. demonstrated that deciduous canine and
rst molar extractions are more effective as a preventive
approach to promote eruption of retained maxillary per-
manent canines positioned palatally or centrally.
n the lateral cephalometric radioraph the normal in- B
clination of the canine compared to the perpendicular to
the Franfurt plane should be about 1 derees Fi. 1..
iher values are related with increased need for orthodon-
tic treatment.
on et al., usin cone-beam computed tomoraphy
T data, stated that the maxillary transverse dimen-
sion had no effect on the occurrence of . accetti
demonstrated that, in  cases not requirin maxillary
expansion, the use of a transpalatal arch T in combina-
tion with deciduous canine extraction can be effective for
the permanent canine eruption.
n the contrary, there is a strict relationship between the C
lac of space and the labially impacted canines, in particu-
lar a transverse maxillary deciency located in the anterior Fig. 13.7 (A–C) Inclination of the canine on lateral cephalometric
portion of the dental arch. analysis parents of this patient refused phase  treatment and upper
esearch usin the T approach stated that buccal left canine impaction occurred  years later.
canine impaction is mostly associated with anterior trans-
verse dental and seletal deciency.
ubects with unilateral or bilateral impacted maxillary Late Diagnosis
canines have smaller maxillary transverse dimensions than
subects without impaction.1 ianosis of upper canine impaction after the expected ae
The effect of rapid palatal expansion as a predictor of of eruption is primarily clinical, with or without the pres-
automatic eruption has been previously demonstrated.  ence of the correspondin deciduous canine. Ectopic or
Early treatment of impacted canines is mandatory in absent canine prominence is usually detected durin the
case of severely resorbed incisors. hen resorption process examination. The information provided by  ives an
is halted, the incisors do not suffer from increased mobility overall picture but cannot determine the proper position of
or discoloration in the lon term. the canine. owever, when it is possible to identify the
154 Principles and Biomechanics of Aligner Treatment

cause of failed eruption e.., a mechanical obstacle such

as odontoma, its removal can allow the tooth to erupt Treatment Planning and
spontaneously. Orthodontic Management
indauer, in his study usin panoramic x-ray, found
that  of  had their cusp tip distal to the lateral inci- The main oal of every orthodontic treatment is not only
sor and remained undetected. the correction of malocclusion but also a ood alinment
T systems provide three-dimensional  imaes and healthy periodontal tissues. eardin impacted ca-
and useful data for a more accurate locatin of impacted nines, the eruption should be in the center of the alveolar
teeth. ride.
T investiations have proven to be superior in detectin urin physioloic eruption there is a fusion between
root resorption compared with conventional radioraphic eratinied iniva and reduced enamel epithelium with
methods intraoral and panoramic radioraphs. The the formation of the unctional epithelium. hen this
amount of resorption detected by T scannin was ap- occurs, a proper arranement of periodontium with an
proximately  hiher. oot resorption of the maxillary adequate band of eratinied tissue, correct sulcular depth,
permanent incisors caused by ectopic eruption of the per- and connective bers inserted on cementoenamel unction
manent canine has an overall prevalence of 1, with a E can be found. f a canine erupts in the alveolar
prevalence that is four times as hih in irls as in boys. mucosa, lac of unctional epithelium may occur, leadin
ental follicles of the ectopically eruptin canines are on to further mucoinival issues Fi. 1..,
averae wider than those of the normally eruptin ca- Teeth erupted in a labial position can promote the thin-
nines. urin eruption, the follicle of the eruptin maxil- nin of the cortical plate and the formation of bony dehis-
lary canine frequently resorbs the periodontal contours of cence or fenestration. This situation is related to lac of
adacent permanent teeth but not the hard tissues of the eratinied iniva and hiher prevalence of recessions
roots. Fi. 1..1,
esorption of neihborin permanent teeth durin max- The adequate amount of eratinied iniva has been re-
illary canine eruption is most liely an effect of the physical ported as between  and  mm, however, thinner ini-
contacts with active pressure durin eruption and cellular val tissue is at hiher ris of inival recession development
activities. The resorptive mechanism seems to be conned durin orthodontic movement. hen conditions do not
to the dental follicle and related to metabolic activation. allow achievement of the eruption with a ood periodontal
an found no sinicant difference of resorption preva-
lence between subects with buccal and palatal impactions.
The dominant predictor for resorption was contact rela-
tionship less than 1 mm.1
nother recent T study found no sinicant correla-
tion between follicle width and the variables of ender, im-
paction side, and localiation of maxillary impacted ca-
nines. ther factors inuencin dianosis and treatment
plannin, such as anylosis and root dilaceration, can be
identied mostly on T imaes. Furthermore, T data
can provide useful information about shape and sie of the
impacted canine, especially if further intraarch space is
required Table 1.1.
ccordin to ecer, the maor reasons for failure are
inadequate anchorae ., mistaen location and di-
rectional traction ., and anylosis .. There is
A
no ae limit for orthodontic recoverin of impacted ca-
nines, but the chance of success decreases with ae. 
study undertaen in adult patients found . success
rate of impacted maxillary canine treatment amon the
adults compared with 1 amon the youner controls,
even thouh the overall lenth of orthodontic treatment
was similar. ll the failed canines were found in the older
adult subroup . years of ae.

Table 13.1 actors Affecting Prognosis

n epth of impaction
n ac of space in the dental arch
n Age of the patient B
n Cooperation of the patient
Fig. 13.8 (A B) Canine eruption in aleolar mucosa.
 13 • Aligners and Impacted Canines 155

A B
Fig. 13.9 (A B) Canine erupted laially ith lac of eratinied gingia and higher ris of recession.

support or in a reasonable treatment time, premolar substi-
tution, retention of the primary canine, or prosthetic reha-
bilitation must be taen into account Fi. 1.1.
ince a proper dianosis is mandatory for correct orth-
odontic and surical plannin, the rst issue to deal with is
depth of impaction. t can be found as a soft tissue impac-
tion, a partial intraosseous impaction, or a deep full bony
impaction.  method of analyin severity of impactions
usin T was proposed by au. This method utilies
the entire three views horiontal, vertical, and axial of a
T imae. ependin on its anatomic location, the cusp
tip and the root tip are each iven a number between  and
 in  taen from a pretreatment imae. The sum of the
cusp tip and root tip scores in the three views dictated
complexity of treatment.
To obtain the eruption at the center of the alveolar ride,
not only the point of eruption of the cuspid but also the path
must be taen into account. irect traction is provided when
relationship with adacent teeth is favorable. f not, the
canine must be moved in a different direction Fi. 1.11.
 recent classication has been proposed to cateorie
maxillary impacted canines as type  hih ris and type
 low ris. Type  teeth represent a hih ris of peri-
odontal damae on neihborin teeth, includin root re-
sorption. They need early exposure to be pulled away from
closer roots. ther teeth must not be moved until they
reach a safe position. Type  canines do not require imme-
diate exposure and can be moved directly in their nal posi-
tion. Therefore, combined orthoperiodontal treatment aims
to uide the canine at the center of the alveolar ride in
three steps:
1. nitial orthodontic phase
. urical intervention
. rthodontic traction and alinment
sually, before the intervention, a preliminary orthodon-
tic phase is needed to ain space in the arch with alinin
and levelin. The initial orthodontic phase should provide a
ood control of the archform and maintain space for the
impacted canine.

A B

Fig. 13.10 (A–E) eep horiontal impaction may undermine the eruption ith a good periodontal support.
Continued
156 Principles and Biomechanics of Aligner Treatment

C D

E Fig. 13.10, cont’d

A B

Fig. 13.11 (A B) ateral incisor on the eruption path of the impacted canine.

The sie of the canine should be calculated automatically
usin linchec software if a contralateral canine is pres-
ent. therwise a diital approximation should be made ac-
cordin to the sie of the other teeth. To avoid any ris of
interference, roots of incisors and premolars close to the
canine should be moved carefully.  proper anchorae is
needed before the surical intervention to support the orth-
odontic traction the use of temporary anchorae devices
Ts can be helpful.
im of the surical exposure is the application of a device
for the traction, such as button or a mesh, as close as possi-
ble to the cusp tip the least amount of bone and eratinied
tissue removal is desirable. Two methods of surical-orth-
odontic traction of impacted teeth can be used: the open ap
and closed eruption techniques. The open technique in-
cludes surical exposure of the crown by either complete
removal of bone and soft tissue directly overlyin the im-
pacted canine or the use of an apically repositioned ini-
val ap without startin orthodontic traction and waitin
on the self-eruption. The closed technique involves elevatin
a full mucoperiosteal ap, exposin the canine crown to
bond an attachment, then suturin. The orthodontic trac-
tion is applied until the eruption of the tooth.
assina found that open surical exposure seems to be
associated with reduced treatment duration and anylosis
ris over the closed technique. Furthermore the closed tech-
nique does not allow direct control of the eruption path,
and the detachment of the orthodontic device may require
a second surery. n the other hand, the rst intention
wound healin can ensure a better postoperative course.
The aim of the postsurical phase is to brin the impacted
tooth into the desired position on the arch. nce the canine
has been exposed, continuous liht forces –  are re-
quired usin elastics or elastomeric chains. The aliner can
be modied with burs or pliers to create proper hoos on
which elastics or elastomeric chains can be anchored.
eavy forces may cause loss of anchorae intrusion and
sinicant root resorption of the adacent anchorae teeth.
hen traction is provided directly by elastomeric chains, if
the patient does not wear aliners adequately, unwanted
forces can develop and unwanted movement of anchorae
teeth can occur. The patient must wear the intraarch elastics
for  hours a day alon with the aliners.
Labial Impactions
ince the amount of attached iniva after eruption and
therefore the nal periodontal health is affected by the sur-
ical technique, labial impactions are more challenin to
manae. ased on the relationship between the impacted
canine heiht and the mucoinival unction , three
different surical techniques are traditionally used to
uncover labially impacted canines: inivectomy, apically
positioned ap, and closed eruption.
The inivectomy is indicated when there is a soft tis-
sue impaction, more than a third of the crown is below
the , and a proper amount of eratinied iniva
about – mm is preserved above the exposed crown.
The apically positioned ap is used in shallow labial im-
pactions when most of the crown is located apically to the
13 • Aligners and Impacted Canines 157
, especially when a little amount of attached iniva is
detected.  minimum of  mm of attached iniva should
be embedded in the ap desin.
The closed eruption technique is recommended when the
position of the crown is coronal to the mucoinival unc-
tion, or if the labiolinual position of the impacted canine
is toward the center of the alveolar ride, to avoid massive
inival and bone removal.
ermette et al. stated that labially impacted teeth
mostly need closed eruption technique to reduce unaes-
thetic sequelae such as increased clinical crown lenth. n
a recent split-mouth study, ee et al. found that after the
closed eruption technique, impacted canines exhibited
sliht but clinically insinicant periodontal recession com-
pared with the contralateral normal tooth. ccurrence of
recession is related to the root developmental stae and
pretreatment depth and anle.
Palatal Impactions
ccordin to ecer and ilberman1 the ideal treatment
approach is from the palatal side. nitial traction should be
applied in a linually downward direction to prevent inter-
ference with the neihborin teeth.
 recent review by arin stated that when a unilateral
 is exposed and alined, there is a small periodontal
impact with no clinical relevance in the short term they
found no difference in periodontal health when the open
and closed techniques were compared. efore orthodontic
treatment, the open technique involves surical exposure
of the canine and the overlyin palatal tissue removal.
ealin is attained by secondary intention.  lare removal
of bone and inival tissue can lead to a sinicative loss of
clinical attachment and inival recession so that this tech-
nique should be avoided in cases of deep impaction. Fur-
thermore, damae of the E can promote an increased ris
of anylosis. The closed technique involves uncoverin
the canine, attachin an eyelet and old chain, and then
suturin the palatal mucosa bac over the tooth., n this
case, a force is applied on the tooth to speed up the eruption.
riticality of this method is the possible detachment of the
orthodontic device. owever, the rst intention wound
healin can lead to better periodontal and aesthetic out-
comes with lower morbidity for the patient.
linical ase
FIRST VISIT
ate: --1
ender: ale
e: 1y m
ORTHODONTI DINOSIS
eletal
n   ,  
ental
n olar  , canine  nonassessible, deep bite, increased
, spaces between teeth
158 Principles and Biomechanics of Aligner Treatment

Facial . urical exposure

n Flat prole . Final alinment
ultiple aenesis: 1, 1, , , 1, , 
mpacted: 1, ,  TRTNT RORSS
Fis. 1.1, 1.1, and 1.1 are provided.
Fis. 1.1 and 1.1 show details of the treatment proress.
TRTNT N
FIN
1. ral hyiene instructions and motivation
. nterior diastemas closure and anchorae preparation Fis. 1.1, 1.1, and 1.1 show nal treatment results.

A B C

Fig. 13.12 (A–C) Clinical case study aseline extraoral.

A B

Fig. 13.13 (A–E) Clinical case study aseline intraoral.

 13 • Aligners and Impacted Canines 159

C D

Fig. 13.13, cont’d

A B

Fig. 13.14 (A–) Clinical case study aseline xrays.

Continued
160 Principles and Biomechanics of Aligner Treatment

Fig. 13.14, cont’d

 13 • Aligners and Impacted Canines 161

Fig. 13.14, cont’d

Continued
162 Principles and Biomechanics of Aligner Treatment

Fig. 13.14, cont’d

A B

Fig. 13.15 (A–E) Clinical case study progression.

 13 • Aligners and Impacted Canines 163

C D

Fig. 13.15, cont’d

A B

Fig. 13.16 (A–) Clinical case study progression.

Continued
164 Principles and Biomechanics of Aligner Treatment

C D

E F

Fig. 13.16, cont’d

A B C

Fig. 13.17 (A–C) Clinical case study extraoral nal.

 13 • Aligners and Impacted Canines 165

A B

E Fig. 13.18 (A–E) Clinical case study intraoral nal.

166 Principles and Biomechanics of Aligner Treatment
Fig. 13.19 (A B) Clinical case study nal xrays.
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computed tomoraphic study. nle Orthod. 1:-.
. accetti T, iler , camara r . n T on treatment of
palatally displaced canines with E andor a transpalatal arch.
Eur J Orthod. 11:1-.
. connell T, offman , Forbes , et al. axillary canine im-
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maxillary canine impaction: a perspective based on cone-beam
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11:-.
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transverse dimensions in subects with and without impacted canines:
a comparative cone-beam computed tomoraphy study. Am J Orthod
Dentofacial Orthop. 11:-.
. eran , camara r , accetti T, et al.  prospective lon-term
study on the effects of rapid maxillary expansion in the early mixed
dentition. Am J Orthod Dentofacial Orthop. 1:1-.
. outolou , ostai . Effect of surical exposure technique, ae,
and rade of impaction on anylosis of an impacted canine, and the
effect of rapid palatal expansion on eruption: a prospective clinical
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. ecer , haushu . on-term follow-up of severely resorbed max-
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. indauer , ubenstein , an , et al. anine impaction
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11:1-, -.
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. erlin , Ericson . ow a computeried tomoraphy examina-
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and ectopically positioned maxillary canines. Angle Orthod.
1:-1.
. Ericson , urol . adioraphic examination of ectopically eruptin max-
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. Ericson , erlin . The dental follicle in normally and ectopically
eruptin maxillary canines: a computed tomoraphy study. Angle
Orthod. 11:-.
1. Ericson , erlin , Falahat . oes the canine dental follicle cause
resorption of permanent incisor roots  computed tomoraphic study
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. an , un , Fields , et al. axillary canine impaction increases
root resorption ris of adacent teeth: a problem of physical proximity.
Am J Orthod Dentofacial Orthop. 11:-.
13 • Aligners and Impacted Canines 167
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. a̌suyu  , ahraman F, şayan . Three-dimensional
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impacted canines on cone-beam computed tomoraphy. Oral adiol.
11:-.
. Evans . anaement of impacted maxillary canines. n: Eliades T,
atsaros . The OrthoPerio Patient linical Eidence  Therapeutic
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ment of impacted maxillary canines. Am J Orthod Dentofacial Orthop.
1:-.
. ecer , haushu . uccess rate and duration of orthodontic
treatment for adult patients with palatally impacted maxillary
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. ermette E, oich , ennedy . ncoverin labially impacted
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. rban . Orban’ Oral itology and Embryology. th ed. t ouis, :
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and therapy in children. J Periodontol. 1:-.
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iniva and inival health. J Periodontol. 11:-.
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children. ASD J Dent hild. 11:-.
. orman . revalence and etioloy of inival recession. J Periodontol.
1:1-.
. perry T, peidel T, saacson , et al. The role of dental compen-
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. iyasato , rier , Eelber . inival condition in areas of
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. ennström , indhe , yman . ole of eratinied iniva
for inival health. linical and histoloic study of normal
and reenerated inival tissue in dos. J lin Periodontol.
11:11-.
. ennström , indhe , inclair F, et al. ome periodontal tissue
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. rescini , ieri , uti , et al. rthodontic and periodontal
outcomes of treated impacted maxillary canines. Angle Orthod.
:1-.
. au , an , allerano , et al.  novel  classication system
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1-.
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. ecer , hpac , hteyer . ttachment bondin to impacted teeth
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1. ee , hoi , hoi , et al. abially impacted maxillary canines
after the closed eruption technique and orthodontic traction:
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11:-.
. ecer , ilberman . The palatally impacted canine: a new approach
to treatment. Am J Orthod. 1:-.
. arin , enson E, Thind , et al. pen versus closed surical
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. ohavi , ecer , ilberman . urical exposure, orthodontic
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. rescini , ieri , uti , et al. hort- and lon-term periodontal
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orthodontic approach. J lin Periodontol. :-.
 14 Aligner Orthodontics in
Prerestorative Patients
KENJI OJIMA, CHISATO DAN, and TOMMASO CASTROFLORIO
Introduction
According to a recent American Association of Orthodon-
tists statement, today one in four orthodontic patients is
an adult.1 In this specic category of patients, orthodon-
tics can be called on to treat either primary malocclusions
that have not been treated before or secondary malocclu-
sions due to orthodontic relapse or pathologic tooth mi-
gration related to periodontal disease (see Chapter 1.
Advances in orthodontics have also made treatment more
comfortable and less noticeable than ever for individuals
of all ages. any of today’s treatment options are de-
signed to minimie the appearance of the appliance to
better t any lifestyle. Apart from the innovations in the
eld, the increasing demand of orthodontic treatment
from adult patients is due to an increased aareness by
patients of the need for good oral health, enabling the pa-
tient to reach adulthood ith a greater number of teeth in
the mouth. It also happens by the increase on esthetic
reuirement from society.  espite possible functional
problems, many of those seeing orthodontic treatment
are een to improve dental esthetics and, potentially, their
uality of life regarding both functional aspects and ap-
pearance. he relative importance of esthetics in current
society is understood hen analying the positive attri-
butes associated ith physical attractiveness.
any of the adults looing for orthodontic treatment
have orn or abraded teeth, previous restorations, miss-
ing teeth, supraeruption and occlusal plane discrepan-
cies, malformed teeth, collapse of the vertical dimension
due to the loss of posterior teeth, and many other prob-
lems reuiring an interaction beteen orthodontics and
restorative dentistry. oever, the connection beteen
the to specialties is reuired for young patients hen
agenesis spaces should be managed or hen the recovery
of a proper smile esthetics reuires cron shape modi-
cations.
Orthodontic diagnosis aims, among others, to deter-
mine the degree of harmoniation reuired to correct
dental or dentomaillary disorders and to indicate hether
prosthetic or restorative compensation is needed and hat
form it should tae. ental professionals should alays
carefully consider tooth position in prosthodontic treat-
ment to determine hether orthodontic treatment can
improve prosthodontic treatment outcomes. Controlling
tooth position ith orthodontics can help the prosthodon-
tist in creating restorations that are more stable, func-
tional, and esthetic.
168
Space Management
in the Anterior Region
pace management represents the eld in hich the cooper-
ation beteen orthodontist and prosthodontists is very com-
mon. he most freuent reason is represented by agenesis,
especially of the upper lateral incisor, because of its relative
high prevalence and impact on a high esthetic value area.
atients ith congenitally missing maillary lateral incisors
often need a challenging interdisciplinary treatment, hether
canine substitution, single implants, or tooth-supported resto-
rations are chosen. Currently, it ould be inappropriate to re-
move enamel and dentin to place crons on adacent teeth in
patients ith dental agenesis, mainly if these individuals have
no restorations or ear of their eisting teeth. In case of uni-
lateral agenesis of the maillary lateral incisor, space closure
should not be used, ecept in eceptional cases, because of
subseuent esthetical and functional problems.
If the treatment plan calls for opening of the edentulous
spaces, implants ould be an ideal alternative for replacing the
missing teeth. esearch has shon that the success rate of
implants is very high. oever, maillary lateral incisor im-
plants are challenging aesthetically. he amount of space is
often small, the alveolar ridge may be decient, the papillae are
occasionally short, the adacent roots could be too close, the
gingival levels may be uneven, and the patient could be too
young. Any of these issues could compromise the aesthetic
outcome of even the nest surgical implant placement.
In this approach, orthodontic treatment combines
1. unctional placement of the canine
. Creation of sufcient space to accommodate a cosmetic
replacement for the missing lateral incisor
oring ith aligners, the functional placement of the
canine reuires the use of attachments to properly control the
movement of the root in the three dimensions. A good option
to obtain predictable movements is alays represented by
their seuentialiation. If the canine reuires distaliation,
mesiodistal root tipping, and torue control, then a good
suggestion is to plan distaliation steps of  mm, application
of mesial root tipping of at least  degrees every  mm of
distaliation, and (only once distaliation and mesiodistal root
tipping have been completed planning the root torue infor-
mation.1 he control of all those movements can be achieved
ith the use of rectangular and vertical attachments.
If a patient is congenitally missing one maillary lateral
incisor, the amount of space to accommodate a cosmetic re-
placement is determined by opposite lateral incisor. oever,
in some patients the contralateral incisor could be peg

shaped. If this is the case, management of spaces should be
performed on the basis of surrounding teeth and tissue es-
thetics and function. he same approach should be used
hen both lateral incisors are congenitally missing.
he fundamental criteria for esthetic analysis should in-
clude facial, dentogingival, and dental esthetics.11 In recent
years, several computer softare programs for digital smile
design ( have been introduced to clinical practice and
research. hey are multiuse conceptual tools that can
strengthen diagnostic vision, improve communication, and
enhance treatment predictability by permitting careful
analysis of the patient’s facial and dental characteristics
that may have been overlooed by clinical, photographic, or
diagnostic cast-based evaluation procedures.1
ith today’s implant technology, assuming a .-mm
lateral incisor implant, most surgeons ould probably be
comfortable placing a maillary lateral incisor implant in a
patient ith an interradicular space greater than . mm,
leaving at least 1 mm of alveolar bone on either side of the
implant. If the interradicular space ere less than  mm,
14 • Aligner Orthodontics in Prerestorative Patients 169
many surgeons ould suggest orthodontic retreatment.
herefore, speaing specically to minimiing the ris of
root movement during retention that ould impede im-
plant placement, Olsen and oich1 recommend leaving
etra space for the surgeon (i.e., a minimum of . mm
beteen the crons and . mm beteen the roots. his
correlates ell ith the space traditionally suggested for
implant placement of 1 mm on either side of the implant.
Case Study
A -year-old female presented ith the chief complaint of
an unaesthetic lateral prole due to protruded upper teeth,
in addition to loer dental croding. he had a short face,
an acute nasolabial angle, a mildly conve prole, and lip
incompetence, ith class I canine and molar relationships
and signicant overet and overbite (ig. 1.1. urther-
more multiple restorations ere present. he panoramic
radiograph conrmed that 1. as missing (ig. 1..
Fig. 14.1 Initial intraoral pictures showing multiple restorations.
170 Principles and Biomechanics of Aligner Treatment
Fig. 14.2 Initial orthopantomograms.
his patient did not ish to change her facial esthetics
but to merely improve the appearance of her anterior teeth.
herefore the goals of esthetic interdisciplinary treatment
ere to reduce the protrusive prole and obtain a class I
canine occlusion, ith normal overet and overbite, by
means of orthodontic treatment enhance dental esthetics
and the smile line ith orthodontics and prosthetic restora-
tions and replace the upper right lateral incisor ith an
implant.
rior to clear aligner treatment, the dental bridge from
the upper right canine to the upper left lateral incisor as
sectioned and polyvinyl siloane ( impressions ere
taen. Clear aligner treatment in the upper arch as de-
signed to intrude and retract the anterior teeth, supported
by class II elastics to bonded buttons on the upper canines
and loer rst molars. In the loer arch, intrusion and
proclination of the anterior teeth ere planned. A tempo-
rary resin pontic replaced the missing upper right lateral
incisor during aligner treatment (igs. 1., 1., and
1.. At the conclusion of 1 months of aligner treat-
ment, the severe overet and overbite ere improved, and
the original vertical dimension as unaltered. An upper
right lateral incisor implant as placed, folloed by nal
esthetic restorations (igs. 1., 1., and 1..
Space Management
in the Posterior Region
he mesial tipping of mandibular second molars is a
freuent source of reuest for orthodontic intervention by
restorative dentists. Inadeuate mandibular arch length,
 14 • Aligner Orthodontics in Prerestorative Patients 171

Fig. 14.3 Clear aligner treatment with attachments and buttons

was started. The upper front xed restoration was sectioned
prior the orthodontic treatment start. Class II elastics anchored
on upper canines and lower rst molars were used to reinforce
canine class I relationship.

Fig. 14.4 An implant was placed in . area.

Continued
172 Principles and Biomechanics of Aligner Treatment

Fig. 14.4, cont’d

A B

Fig. 14.5 rontal view of . implant with A and without B aligner.

Fig. 14.6 rontal view of the nal upper anterior restoration.

 14 • Aligner Orthodontics in Prerestorative Patients 173

Fig. 14.7 inal intraoral pictures.

Fig. 14.8 inal extraoral pictures and xras.

Continued
174 Principles and Biomechanics of Aligner Treatment
Fig. 14.8, cont’d
ecessive teeth sie, loss of the adacent rst molar, premature
eruption of the mandibular third molar, and unusually me-
sial eruption pathay of the second molar can also cause its
partial or total impaction.1 achrisson1 stated that in case
of severe mesial tipping of loer second molars, periodontal
status can be aggravated, ith angular bone loss, and an
apparent pocet at the mesial surface of a tipped mandibular
molar. In ecessive inclination cases, overeruption of the
antagonist molar ith subseuent premature contacts and
occlusal interferences hamper prosthetic intervention.
epositioning of the second molar eliminates pathologic
condition and facilitates the placement of a prosthetic res-
toration. Among the limitations of aligners, severely tipped
teeth (. degrees ere included.1 prighting a severe
mesial tipped molar using aligners could be uite risy
since the tting loss could produce a orsening of the me-
sial tipping. As ell described by renia,1 if the tooth is
not performing the desired movement, the aligner ill sur-
render to the stiffer teeth and become distorted. Its gingival
edges move aay from the teeth, and no force can be e-
erted in the gingival area hile the force is concentrated
only in the occlusal part. his distortion prevents any pos-
sible couple to be developed, and no bodily movement of the
tooth is possible. his occlusal force encourages intrusion
that, for a severe mesial tipped molar, means orsening of
its tipping. herefore hen planning, uprighting of molars
ith aligners is preferable to reduce the velocity of the an-
gular movement and to accurately control the tting of
aligners at every appointment (igs. 1. through 1..
he intrusion effect and thus the orsening of the mesial
tipping could be accelerated if a large attachment has been
displayed on the buccal surface of the molar and if the
aligner is losing tting. Attachments are helpful especially
in those cases ith rounded shape teeth but close controls
in the ofce are reuired. o increase the efciency of the
uprighting mechanics and to increase the stiffness of the
aligner, pontics mesially to the tipped teeth should be
avoided. ontics are euivalent to loops bent on an arch-
ire. hey increase elasticity and then a potential unde-
sired distortion of the aligner if it is going to lose tting.
he use of temporary anchorage devices (As can sup-
port the uprighting of severe mesially tipped molars. or
this instance, cutouts should be planned on the aligner por-
tion covering the tipped teeth to permit the placement of
bonded buttons or bracets or tubes on the tooth cron,
hich can be connected ith sectional mechanics or elastic
moduli to As. A systematic revie indicated mandibular
molar uprighting as a freuent and complicated procedure,
hich reuires good anchorage control.1 ven a small
amount of anchorage loss can result in aligner distortion
ith adverse effects, not only on the moving tooth but also
on other tooth units. he introduction of As as anchor-
age control auiliaries as a “game changer” in orthodon-
tics, maing, among others as discussed in other chapters
of this boo, molar uprighting easier and reliable ith
aligner orthodontics.
 14 • Aligner Orthodontics in Prerestorative Patients 175

Fig. 14.9 Initial orthopantomogram of a patient for which a prerestorative orthodontic treatment was reuired.
. and . were congenitall missing. The interdisciplinar treatment plan was designed to recover a proper
interarch relationship and preparing the case for future restorations on upper front teeth and in the lower arch
after the uprighting of . and intrusion of overerupted ..

Fig. 14.10 Initial intraoral and ClinChec lateral views in relation to the mesial tipping of . caused b the
premature loss of ..

Fig. 14.11 Initial intraoral and ClinChec occlusal views in relation to the mesial tipping of ..
176 Principles and Biomechanics of Aligner Treatment

Fig. 14.12 Attachment conguration used to recover a proper alignment and leveling of the arches and the
uprighting of .. Pontic was not prescribed in . area to increase the stiffness of the aligner.

Fig. 14.13 inal intraoral and ClinChec lateral views with successful uprighting of ..

Fig. 14.14 inal intraoral and ClinChec occlusal views with successful uprighting of ..
 14 • Aligner Orthodontics in Prerestorative Patients 177

Fig. 14.15 Initial intraoral and ClinChec lateral views in relation to the overeruption of . caused b the pre
mature loss of ..

Fig. 14.16 Initial intraoral and ClinChec occlusal views of the upper arch.

Fig. 14.17 Attachment conguration used to recover a proper alignment and leveling of the arches.
178 Principles and Biomechanics of Aligner Treatment

Fig. 14.18 inal lateral intraoral and ClinChec views of the right side showing intrusion and leveling of
. obtained with the aid of a buccal miniscrew and a segmented auxiliar arch bonded on . and .
after proper modication of the aligners. Intrusion of . was planned to level gingival edge to the . one. An
implant was placed in . area during the nal stages of the orthodontic treatment.

Fig. 14.19 inal intraoral and ClinChec occlusal views of the upper arch.

Fig. 14.20 inal orthopantomogram.


Management of Posterior
ererupted Moars
It is common for adult patients ith dental loss, particu-
larly of molars and premolars, to have an etrusion of the
antagonist. An early loss of any molar is bound to cause
supraeruption of the opposing molar into the available
space. Overeruption of such a molar can lead to occlusal
interference and functional disturbances and cause great
difculty during prosthetic reconstruction.1
Orthodontic treatment of overerupted molars has alays
been considered challenging by orthodontists, even more
hen considering aligner treatment. his is primary due to
the great volume of these teeth and to the need for ecellent
anchorage control to have the reuired forces directed
through the center of resistance of the tooth. urthermore
molar intrusion is one of the less predictable movements to
be performed ith aligners. According to a recent paper,
posterior intrusion could be taen into account ith align-
ers if a maimum .- to 1-mm molar intrusion has been
planned.1
In these cases, the use of As along ith orthodontic
biomechanics incorporated into the aligner treatment plan
is used to obtain better case control hile minimiing un-
anted side effects. o avoid tipping of the molar that
should be intruded, forces need to be applied both buccally
and lingually, and interproimal spaces are reuired to
obtain intrusion.
herefore, hen planning the mechanics reuired to ob-
tain intrusion of an overerupted molar ith aligners, it is
important to have interproimal spaces open to permit the
intrusion movement, planning interproimal reduction and
controlling that at every stage of movement the tooth has
no interproimal friction. Attachments should be prescribed
on adacent teeth to provide anchorage (rectangular and
horiontal attachments but not on the tooth reuiring in-
trusion. oever, if the tooth reuiring intrusion is the most
distal one, then a buccal attachment should be placed.
As can be of help in increasing the amount of molar
intrusion over the maimum value of predictability ith
aligners only (see igs. 1. through 1.. o mini-
implants can be installed on each side, one buccally and
another palatally, to have more controlled movement and
to mae it less comple for the professional, ith more pre-
dictable results.1 or pure intrusion, a total of three mini-
implants could be used in a tooth, in agreement ith ac-
cini et al. he seletal anchorage can be used connecting
it to buttons bonded on the tooth cron ith elastic chains
or ii coils, and, in this case, cutouts should be planned on
the aligner. Another option could be represented by the use
of elastic chains or other elastic modulus connecting the
palatal and buccal miniscres, passing over the occlusal
surface of the aligner.
A nite element study investigating the use of As for
molar intrusion shoed that unilateral force unleashed
higher stress in root ape and higher evidence for dental
tipping directed to mini-implant sites the bilateral force
promoted a more homogeneous stress distribution ithout
evidence of dental tipping. ilateral intrusion techniue
suggested a vertical movement of intrusion and loer prob-
ability of root ape resorption.1
14 • Aligner Orthodontics in Prerestorative Patients 179
Management of Patients With a
History of Temporomandiuar
isorders
emporomandibular disorders (s are a group of mus-
culoseletal and neuromuscular conditions involving the
temporomandibular oints (s, the masticatory mus-
cles, and associated tissues. Current understanding and
evidence-based literature failed to demonstrate a relation-
ship beteen various occlusal factors and  signs and
symptoms.  has moved from a dental and mechanical-
based model to a biopsychosocial and medical model
that integrates a host of biologic, behavioral, and social
factors to the onset, maintenance, and progression of
. anagement of  is typically symptomatic, aimed
at decreasing pain, decreasing loading on the muscles
and oints, and facilitating the restoration of function
and uality of life of patients. Orthodontics is generally
described as neutral in that it neither causes, cures, nor
mitigates .
ome early case reports shoed for some patients treated
ith aligners, a muscle tenderness and ear facets on
their aligners. everal clinicians speculated about the
ear facets concluding that aligners may have acted as
occlusal splints. A more credible hypothesis is related to
an adaptation mechanism involving repetitive tooth clench-
ing. erhaps it is possible that patients are triggered to
clench on the aligners to alleviate orthodontic pain. As
previously reported, orthodontic pain can be reduced by
repetitive cheing of gum or plastic afers during the rst
 hours after the appliance is activated. Aligner cheing
and clenching can result in ear facets and muscle tender-
ness in some patients treated ith aligners. herefore it is a
possibility that patients undergoing clear aligner treatment
may have transient symptoms of facial muscular pain and
 as a result of repetitive clenching to relieve orthodon-
tic pain.  his is the reason hy aligners should not be
used in patients ith active s. As a general rule, 
needs to be managed before starting any orthodontic treat-
ment. reatment should address not only the physical diag-
nosis but also the psychologic distress and the psychosocial
dysfunction. he rst stage in  treatment is symptom
focused and behavioral, and it includes (as determined by
the problem list patient education, physiotherapy, pharma-
cotherapy, psychologic therapy (e.g., cognitive behavioral
therapy, stress management, and self-regulatory sills,
control of overuse behaviors, and intraoral  appli-
ances. Only once symptoms have been controlled and
ith the aareness that s are cyclic in nature (there-
fore ith a proper informed consent available, an orth-
odontic treatment can be planned. he folloing case is
helpful in eplaining a possible aligner orthodontics ap-
proach to a  patient after a rst conservative phase and
pain relief.
DIAGNOSIS AND TRATNT AN
he reasons hy aligners could be used to move teeth
orthodontically in a patient ith a history of  are
represented by the possibility of accurately planning the
seuence of movements, thus reducing and preventing
180 Principles and Biomechanics of Aligner Treatment
phases in hich premature contacts can trigger the occlu-
sal hypervigilance of some patients and by the possibility of
using the aligners as physical pro memoria to help the pa-
tient to avoid clenching and gnashing of the teeth at least
during the aae part of the day. ince the possibility of
involuntary clenching or gnashing to alleviate orthodontic
pain has been described, the orthodontic treatment plan
should consider small amounts of movement from the very
early stages of treatment to reduce orthodontic pain as
much as possible.
Case Study
A -year-old female patient presented ith anterior open
bite, shift of the loer midline and of the mandible toard
the left side, canine class II on the left side, and canine class
I on the right side. urthermore diastemas ere present in
the loer arch, and posterior ed prosthodontic restora-
tions ere present (ig. 1.1. he patient had a history of
 ith headaches in the temple region, nec pain, and
bac. All these symptoms ere controlled ith physiother-
apy, cognitive behavioral therapy, and pharmacotherapy
only once the pain as relieved as the treatment plan
designed.
he panoramic -ray highlighted the presence of inter-
proimal spaces in the loer arch and the missing of both
loer rst molars ith conseuent installation of bridges
(ig. 1.. A  cone-beam computed tomography
(CC scan highlighted a protruded position of the right
condyle (ig. 1..
he first step of the interdisciplinary treatment con-
sisted in the substitution of the old prosthetic restora-
tions ith provisional ones built in a stabilied mandible
position thans to a repositioning splint built by the
prosthodontist in centric relation (igs. 1., 1.,
and 1..
Once the provisional bridges ere ed, an intraoral scan
as performed to start aligner treatment. he virtual treat-
ment plan is illustrated in igs. 1. and 1.
Fig. 14.21 Initial intraoral pictures.
 14 • Aligner Orthodontics in Prerestorative Patients 181

Fig. 14.22 Initial extraoral pictures and orthopantomogram.

Fig. 14.23 Initial conebeam computed tomograph scans highlighting the asmmetric condles position.
182 Principles and Biomechanics of Aligner Treatment

Fig. 14.24 ower occlusal splint.

Fig. 14.25 Conebeam computed tomograph scans showing condle repositioning due to the splint effect.

Fig. 14.26 Acrlic provisionals used to eep the new mandible position during the orthodontic treatment.
 14 • Aligner Orthodontics in Prerestorative Patients 183

Fig. 14.26, cont’d

Fig. 14.27 Initial stage of the ClinChec.

184 Principles and Biomechanics of Aligner Treatment
Fig. 14.28 inal stage of the rst ClinChec.
A phase I treatment as planned ith  aligners and
concluded in  months ith a -day aligner change regi-
men (supported by additional vibrational forces ith Ac-
celeent Aura, OrthoAccel Inc., ellair, , A.
ig. 1. illustrates the intraoral situation at the end
of phase I. o complete the orthodontic treatment, the
pontic sections of the loer left and right bridges ere cut
and a ne intraoral scan as performed to design
the biomechanics reuired for the nal phase of the
orthodontic treatment. hen  aligners ere planned
and a - to -day aligner change regimen as applied to
close the treatment in 1 months. Additional vibrational
forces ere used in this phase, too (igs. 1. and 1.1.
pace for the installation of a rst molar implant as
secured (igs. 1. and 1..
inal pictures sho the alignment of the midlines and
the set of a functional occlusion ith good esthetic results
(igs. 1. and 1..
 14 • Aligner Orthodontics in Prerestorative Patients 185

Fig. 14.29 Intraoral pictures at the end of the rst set of aligners.

A B

Fig. 14.30 A ateral and B posteroanterior xras at the end of the rst set of aligners.
186 Principles and Biomechanics of Aligner Treatment

Fig. 14.31 Intraoral pictures at the end of the second set of

aligners.

Fig. 14.32 inal stage of the second ClinChec.

 14 • Aligner Orthodontics in Prerestorative Patients 187

A B

Fig. 14.33 A inal orthopantomogram and B lateral xra.

Fig. 14.34 Intraoral pictures showing the lower implants and the nal prosthodontic restorations.
Continued
188 Principles and Biomechanics of Aligner Treatment

Fig. 14.34, cont’d

Fig. 14.35 inal extraoral pictures.


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1. affarel I, eira , uimarães , et al. iomechanics for orth-
odontic intrusion of severely etruded maillary molars for functional
prosthetic rehabilitation. Case Rep Dent. 111.
1. eir . Clear aligners in orthodontic treatment. Aust Dent J.
1(suppl 1-.
. accini , Cotrim-erreira A, erreira , et al. fciency of to
protocols for maillary molar intrusion ith mini-implants. Dental
Press J Orthod. 11-.
1. ugii , arreto C, rancisco ieira-únior , et al. truded
upper rst molar intrusion comparison beteen unilateral and
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-.
. andasamy , inchuse . Orthodontics and . In andasamy
, reene C, inchuse , et al., eds. TMD and Orthodontics. A
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. ran , ou , ebiolo , et al. Impact of clear aligner therapy on
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 15 Noncompliance Upper Molar
Distalization and Aligner
Treatment for Correction
of Class II Malocclusions
BENEDICT WILMES and JÖRG SCHWARZE
Upper Molar Distalization
in Aligner Treatment
The distalization of the upper molars may be considered as
a treatment option for patients with an angle class II maloc-
clusion characterized with an increased overjet and/or an-
terior crowding. There has been an increasing trend in the
clinical use of purely intraoral appliances, which require
minimal need for patient cooperation. nfortunately, most
tooth-borne appliances for upper molar distalization pro-
duce an unwanted side effect of anchorage loss resulting in
maillary incisor proclination, reported to be  to 
of observed tooth movement. ure bodily tooth movement
with sequential plastic aligner therapy is challenging to
achieve to a high degree of predictability. s a consequence,
molar distalization is limited when relying on aligner move-
ment alone. hile there are limited reports of successful
upper molar distalization of up to . mm in the literature,
a very long treatment time and high level of patient compli-
ance are epected with requirement for intermaillary class
II elastics to be worn during the long period of the sequen-
tial upper molar distalization. oreover, the potential side
effects of class II elastics must be considered in terms of
mesial shift of the lower anchorage teeth.
To minimize anchorage loss and need for class II elastics,
mini-implants have been incorporated into the design of
maillary distalization appliances.  ini-implants can be
positioned intraorally with minimal degrees of surgical
invasiveness, are readily integrated with concomitant bio-
mechanical initiatives, and are relatively cost effective.-
arious designs of implant supported distalization appli-
ances have been published. The retromolar region is an
unsuitable area for mini-implant insertion due to the unfa-
vorable anatomic conditions poor bone quality and thic
soft tissue. dditionally, the alveolar process has also been
shown to be inappropriate in cases of a desired molar distal-
ization since the mini-implants are in the direct path of the
moving teeth resulting in a failure rate that is much higher
as compared to the anterior palate. Therefore, the palatal
area posterior from the rugae T zone seems to be the
preferred insertion site for mini-implants where the
treatment objective is for distal movement of the maillary
molars without associated anchorage loss and maillary
incisor displacement. urthermore, good bone quality with
190
thin attached mucosa implies minimal ris of tooth-root
injuries and a very high success rate in the anterior palatal
region. In contrast to treatment strategies involving the
interradicular positioning of mini-implants, the molar
teeth can be distalized, and the premolars are free to move
distally due to the stretch of the interdental bers without
any interference since the palatally positioned mini-
implants are not in the path of moving teeth. ithin the
T zone, the mini-implants can be inserted in a median or
paramedian orientation, with both insertion sites show-
ing a similar stability.
Clinical Procedure and Rational
of the Beneslider
The eneslider- is a maillary molar tooth distalization
appliance, principally designed on the use of one or
two mini-implants coupled in a median or paramedian ori-
entation in the anterior palate ig. .. y modifying
the angulation of the .-mm stainless steel wire, it is pos-
sible to achieve a simultaneous intrusion or etrusion of
the molars.- The distalization forces are transferred to
the molars by the use of bonded tubes. The advantages of a
bonded tube are esthetics, and the adaptability and t of the
aligners is not undermined by the presence of stainless steel
molar bands. The aligner material could cover this bonded
connection ig. . or the aligner could be cut out in this
connection area “button cutout” ig. ..
It seems advantageous that the eneslider appliance can
be tted directly without the requirement for adjunctive
laboratory wor in terms of welding or soldering, or the
need to record an intraoral impression. lternatively, the
clinician has the choice to record an intraoral impression
and transfer the clinical setup to a plaster cast model
using an impression cap and laboratory analogue from the
enet system.
ollowing distalization of the maillary molar teeth, steel
ligatures can be used see ig. . or springs removed
see ig. . to modify the eneslider from an active dis-
talization device to a passive molar anchorage device. The
primary objective is to stabilize the maillary molar teeth
during the retraction of the maillary anterior teeth. ur
eperience in using the eneslider appliance in conjunction
with aligners commenced with a two-phase approach
 15 • Noncompliance Upper Molar Distalization and Aligner Treatment for Correction of Class II Malocclusions
Fig. 15.1 The Beneslider appliance is based on one or two mini-
implants with echangeable abutments
Fig. 15.2 The aligners can coer the bonded connection lie a big
attachment After distalization steel ligatures are to modif the actie
Beneslider into a passie anchorage deice
Fig. 15.3 The aligners can be cut out in this connection area “button
cutout” prings are remoed in this case to modif the actie
Beneslider into a passie anchorage deice
191
the initial phase involving molar distalization and the
secondary phase for the nal detailing of the occlusion
with sequential thermoplastic aligners. ith a two-phase
approach, an impression or scan is recorded after distaliza-
tion. To reduce the total treatment time, we now recom-
mend simultaneous distalization with the eneslider and
alignment with sequential aligners. ith a single-phase
approach, the impressions for aligners are taen prior to
distalization of the maillary molars, and the anticipated
tooth movement to be produced by the eneslider appliance
is programmed in the digital software platform. or distal-
ization, either a sequential step-by-step distalization or an
entire maillary arch can be chosen since the stretch of the
interdental bers supports the simultaneous distal drift of
maillary anterior teeth.
If the aligner material should cover the connection area
with the molars see ig. ., the impressions for aligners
should be done after the insertion of the eneslider appli-
ance. The eneslider should be not activated prior to the
delivery of the aligners. If the aligners have a cutout area
see ig. ., the impressions for aligners are able to be
recorded either before or after insertion of the eneslider
appliance. istalization forces can be applied to the rst or
second maillary molar teeth. ur clinical eperiences have
shown that force application to the rst molar is a superior
approach, as direct force application to the second molar
teeth is associated with precocious distalization of the
second molars, leading to improper tracing and tting of
the sequential plastic aligners, a ris that is reduced if the
maillary rst molar teeth are connected to the eneslider.
Clinical Case
 -year-old female patient presented with anterior
crowding class II malocclusion ig. . Table .. The
maillary teeth were migrated mesially, especially on the
left side. ue to the absence of the second lower right molar,
the upper second right molar was elongated.
The patient was very unhappy with the protrusion of
the upper front teeth and specically requested an invisi-
ble orthodontic treatment option to be performed on a
nonetraction basis. ollowing the insertion of two
enet mini-implants in the anterior palate ig. .,
the eneslider appliance was passively installed see
ig. . note springs are not activated. ith the goal
to distalize and intrude the upper right second molar
simultaneously, the guiding wire of the eneslider was
angulated apically see ig. .. econdly, intraoral
scans were recorded for fabrication of clear aligners
Invisalign, lign Technology, Inc..
sing the aligner planning software e.g., linhec, the
molar movements have to be planned parallel to the guid-
ing wires of the eneslider, including the intrusive vertical
component in the rst quadrant. uring the distalization
period, molar derotations and uprighting movements were
not allowed see ig. .. In this patient, a sequential
distalization was chosen. The aligner material should cover
the connection area ig. .. fter delivery and insertion
of the aligners, the eneslider was activated by pushing
the -g iTi springs distally using the activation loc
see ig. .. The maillary molars were to be distalized
192 rinciples and Biomechanics of Aligner Treatment

Fig. 15.4 A -ear-old female patient with an angle class II malocclusion characterized b anterior crowding
and a deep bite
15 • Noncompliance Upper Molar Distalization and Aligner Treatment for Correction of Class II Malocclusions 193

Fig. 15.4, cont’d

Tale 151 Cephalometric ummar

Pretreatment Posttreatment
NBa ° °
N-N ° °
M-N ° °
M-N ° °
NA ° °
NB ° °
ANB ° °
its  mm  mm
U-N ° °
-M ° °
U- ° °
eret  mm  mm
erbite  mm  mm
194 rinciples and Biomechanics of Aligner Treatment

A B

C
Fig. 15.5 After insertion of two Benet mini-implants in the anterior palate A and installation of the Beneslider mechanics B uperimposition
of an intraoral picture of the maillar arch and the ClinChec to demonstrate desired tooth moement directions C

approimately  to  mm. The patient reportedly adapted to

Fig. 15.6 Beneslider was actiated b pushing open springs distall
after delier of the aligners Connection areas of the Beneslider with
the molars are coered b the aligner “big attachment”
the appliance without issue. The panoramic radiograph
denotes bodily distalization of all maillary posterior teeth
after  months ig. ..
uring the follow-up controls, molar distalization is
visible with small spaces between molars and bicuspids
igs. ., ., ., and . note sequential distal-
ization. s soon as the maillary molar teeth were distal-
ized into an angle class I occlusion, steel ligatures were used
between the bonded tube and the activation loc to deacti-
vate the eneslider ig. . see igs. . and ..
The eneslider was converted from a distalization device to
a molar anchorage device. fter all spaces were closed to
the distal, the eneslider was removed and scans for a
renement and molar derotation were recorded. ompre-
hensive treatment was completed after  months, and the
palatal mini-implants were removed without the adjunctive
use of local anesthesia ig. .. pper incisors were
reclined signicantly - has changed from . to
 15 • Noncompliance Upper Molar Distalization and Aligner Treatment for Correction of Class II Malocclusions 195

Fig. 15.7 adiographs after  months of treatment rtopantomograph and lateral -ra after  months of treatment

Fig. 15.8 Intraoral pictures after  months

196 rinciples and Biomechanics of Aligner Treatment

Fig. 15.9 Intraoral pictures after  months showing man small

spaces due to the semiseuential distalization

Fig. 15.10 Intraoral pictures after  months Molars are distalized in a Class I occlusion The Beneslider is
modied into a molar anchorage deice b two steel ligatures which are deactiating the Beneslider rom this
moment bicuspid canine and incisor retractions are following
15 • Noncompliance Upper Molar Distalization and Aligner Treatment for Correction of Class II Malocclusions 197

Fig. 15.10, cont’d

Fig. 15.11 Intraoral pictures after  months

Continued
198 rinciples and Biomechanics of Aligner Treatment

Fig. 15.11, cont’d

Fig. 15.12 Upper arch after  months All spaces were to be closed to the distal ubseuentl the Beneslider
was remoed for renement

Fig. 15.13 Treatment result after  months

15 • Noncompliance Upper Molar Distalization and Aligner Treatment for Correction of Class II Malocclusions 199

Fig. 15.13, cont’d

200 rinciples and Biomechanics of Aligner Treatment
Fig. 15.14 uperimposition of before and after cephalograms -N
Upper incisor retraction is signicant
. degrees ig. ., and the patient was very
happy with the achieved result.
Clinical Considerations
or distalization, either a sequential step-by-step distaliza-
tion or an entire maillary arch can be chosen. In this case,
a sequential distalization was chosen. The advantage of se-
quential distalization is the aligner tting is probably better
because all teeth are enclosed by aligner material, and
therefore bodily retractions of bicuspids and canines can be
achieved easier. isadvantage is the longer treatment time,
which is visible in the case shown in this chapter.
ur initial approach to combine aligner therapy and
the eneslider appliance involved a two-phase protocol 
distalization, and after distalization of the maillary molar,
 impression/scan and nishing with aligners.
dvantages of this two-phase procedure are as follows
n o need for coordination of tooth movement with en-
eslider and aligners
n n epected requirement for fewer aligners to achieve
treatment objectives
 disadvantage of the two-phase procedure is
n n epected increased treatment time
The potential drawbac of the one-phase method is the
coordination between the eneslider appliance and planned
aligner tooth movements. If the distalization force and/or
the rate of distal molar movement are ecessive compared
to the aligner staging, the t and accuracy of the aligner
may be undermined with the appearance of maillary
interdental spacing.  second factor to be considered is
the possibility of insufcient aligner wear by the patient. If
this is recognized during active treatment, the rate of distal-
ization may be reduced or the wear time of on aligner
may be prolonged e.g., wearing each aligner for  wees
instead of one. The rate of the maillary molar distal
movement associated with the use of a eneslider appliance
is approimately . mm per month this rate of molar
distalization speed should be ept in mind when determin-
ing the appropriate aligner staging linhec.
The distalization force can be directly applied to the rst
or second molar teeth. To achieve a maimum retention
with the teeth that are to be moved distally, we recommend
bonding the eneslider to the rst molar teeth instead of
the second molars. If the distalization forces are applied to
the second molars and the aligner tting at the second mo-
lars is not perfect, small unepected spaces can develop in
between the upper rst and second molar teeth. In this situ-
ation, the distalization force must be reduced to regain
aligner tting.
The anterior palate has proven to be the most convenient
region of the mailla for insertion of mini-implants. 
ince there are no roots, blood vessels, or nerves, the ris of
a complication associated with the placement of a mini-
implant is minimal. ven the penetration of the nasal cavity
does not result in any problems. ecently, a /-
manufactured insertion guide was introduced asy river,
arma, Italy, which facilitates safe and precise insertion
of mini-implants in the anterior hard palate, availing the
opportunity for the use of palatal implants to the less
eperienced clinician. econdly, these insertion guides
allow for the insertion of mini-implants and installation of
the appliance in a single ofce visit.
Conclusions
n y using palatal mini-implants and a eneslider device,
unilateral or bilateral distal tooth movement can be real-
ized without anchorage loss and need for class II elastics.
n The eneslider can be easily integrated in aligner ther-
apy by using bonded tubes on the palatal surfaces.
n  combined, single-phase treatment approach with
simultaneous distalization and alignment is possible.
References
. ortini , upoli , iuntoli , et al. entoseletal effects induced by
rapid molar distalization with the rst class appliance. Am J Orthod
Dentofacial Orthop. - discussion -.
. imon , eilig , chwarze , et al. orces and moments generated
by removable thermoplastic aligners incisor torque, premolar
derotation, and molar distalization. Am J Orthod Dentofacial Orthop.
-.
. imon , eilig , chwarze , et al. Treatment outcome and efcacy
of an aligner technique—regarding incisor torque, premolar derota-
tion and molar distalization. BMC Oral Health. .
. inzinger , ulden , ildizhan , et al. nchorage efcacy of pala-
tally-inserted miniscrews in molar distalization with a periodontally/
miniscrew-anchored distal jet. J Orofac Orthop. -.
. aboud , ad , bbott , et al. earch for dar matter at ormula
see tet in nal states containing an energetic photon and large miss-
ing transverse momentum with the T detector. Eur Phys J C Part
Fields. .
. osta , affaini , elsen . iniscrews as orthodontic anchorage
a preliminary report. Int J Adult Orthodon Orthognath urg. 
-.
. anomi . ini-implant for orthodontic anchorage. J Clin Orthod.
-.
 15 • Noncompliance Upper Molar Distalization and Aligner Treatment for Correction of Class II Malocclusions
. elsen , osta . Immediate loading of implants used for
orthodontic anchorage. Clin Orthod es. -.
. udwig , lasl , owman , et al. natomical guidelines for
miniscrew insertion palatal sites. J Clin Orthod. -.
. ourfar , ister , anavais , et al. Inªuence of interradicular
and palatal placement of orthodontic mini-implants on the success
survival rate. Head Face Med. .
. ilmes , udwig , asudavan , et al. The T-zone median vs.
paramedian insertion of palatal mini-implants. J Clin Orthod.
-.
. ienemper , auls , udwig , et al. tability of paramedian
inserted palatal mini-implants at the initial healing period a con-
trolled clinical study. Clin Oral Implants es. -.
. ilmes , rescher .  miniscrew system with interchangeable
abutments. J Clin Orthod. - quiz .
. ilmes , rescher , ienemper .  miniplate system for
improved stability of seletal anchorage. J Clin Orthod. 
-.
201
. ilmes , rescher . pplication and effectiveness of the eneslider
molar distalization device. orld J Orthod. -.
. ilmes , ienemper , udwig , et al. sthetic class II
treatment with the eneslider and aligners. J Clin Orthod.
-.
. ilmes , euschulz , afar , et al. rotocols for combining
the eneslider with lingual appliances in class II treatment. J Clin
Orthod. -.
. ilmes , atyal , illmann , et al. ini-implant-anchored
esialslider for simultaneous mesialisation and intrusion of upper
molars in an anterior open bite case a three-year follow-up. Aust
Orthod J. -.
. ienemper , ilmes , auls , et al. Treatment efciency of
mini-implant-borne distalization depending on age and second-
molar eruption. J Orofac Orthop. -.
. e abriele , allatana , iva , et al. The easy driver for
placement of palatal mini-implants and a maillary epander in
a single appointment. J Clin Orthod. -.
 16 Clear Aligner Orthodontic
Treatment of Patients with
Periodontitis
TOMMASO CASTROFLORIO, EDOARDO MANTOVANI, and KAMY MALEKIAN
Malocclusions Related
to Periodontal Disease
There is no direct inuence between malocclusion and peri-
odontal breakdown; however, quicker progression of peri-
odontal disease is associated with occlusal discrepancies
and is reduced by occlusal treatment.1, t has been demon-
strated that in crowded areas plaque accumulation in-
creases and, with respect to noncrowded areas, an in-
creased number of periopathogenic species can be found.
urthermore, an altered topography of the gingiva and the
alveolar bone is commonly found when teeth are crowded.
There is a strict relationship between crowding and peri-
odontitis because anterior teeth migration is enhanced by
periodontal disease, leading to a further crowding in lower
arch, which then hinders a proper periodontal health. anavi
demonstrated that deep bite is directly related to periodontal
breakdown due to soft tissue impingement on the upper and
lower incisors ig. 1.1. urthermore, multiple types of oc-
clusal contacts have been associated with deeper probing
depths premature contacts in centric relation, posterior pro-
trusive contacts, balancing contacts, combined working and
balancing contacts, and length of slide between centric rela-
tion and centric occlusion. nother correlation was found in
mesially inclined molars where the periodontal destruction
was 1 greater than that found in normally inclined teeth.
Orthodontic Treatment in
Patients With Periodontal Disease
rthodontics is needed in combination with periodontal
and prosthodontic treatment to treat patients with a sec-
ondary malocclusion or in whom there is aggravation of an
eisting malocclusion related to periodontal disease. e-
spite the high number of published articles, there is still a
lack of good evidence about many of the treatments, in-
cluding orthodontics and periodontal therapy.1
The prevalence of pathologic tooth migration T
among periodontal patients has been reported to range
from . to .; periodontal bone loss appears to be
the maor factor in the etiology of T.11 n a recent study,
horshidi et al. found that pathologic migration prevalence
was 11. 1 patients; however, there was no
pathologic migration in patients with mild chronic peri-
odontitis. T prevalence is increased by the severity of
periodontal disease, and no statistically signicant differ-
ence between males and females was found.1
202
n early stages of T, spontaneous correction of mi-
grated teeth sometimes occurs after periodontal therapy.
hen only a light degree of pathologic migration is consid-
ered, it has been hypothesied that this is due to wound
contraction during healing ig. 1..1 oft tissue forces
of the tongue, cheeks, and lips are known to cause tooth
movement and in some situations can cause T. The
transseptal bers play a key role in T by forming a chain
from tooth to tooth and helping maintain contacts between
teeth. f the continuity of the chain is weakened by peri-
odontal disease, the balance of forces is upset, and displace-
ment of the teeth can occur ig. 1..
cclusal factors such as posterior bite collapse, shortened
dental arches, occlusal interferences, and bruism are con-
nected to the etiology of T.
atients with periodontal issues are commonly character-
ied by general aring with spacing between the upper inci-
sors, deepening of the bite sometimes etrusion of a single
tooth can occur, increased overet, and crowding in the lower
incisor region.1 nterposition of the lower lip behind the ared
incisors can worsen the situation. n orthodontic treatment
provided without a proper oral hygiene can result in iatrogenic
damages oving a tooth into an infected infrabony defect can
enhance the destruction of connective tissue.1 owever, a
combined ortho-perio treatment is efcient in the treatment of
periodontitis and could effectively decrease the levels of in-
ammatory cytokines.1 urthermore, the treatment should
aim for the patient’s epectations and aesthetic goals.
rthodontic treatment can allow the optimiation of
clinical situations1 such as
n eveling of bone peaks
n ringing a tooth back to the alveolar ridge
n mplant site preparation
rthodontic treatment is indicated when the worsening
of periodontal status can be promoted by tooth malposition
such as
n evere tooth crowding
n remature contacts
n evere deep bite associated with direct trauma on peri-
odontal tissues
n esial inclination of molars associated with angular
bony defect
rthodontic treatment is mandatory when
n The periodontal disease has caused T and abnormal
tooth mobility.
n  previous orthodontic therapy made with unskillful-
ness has created further periodontal tissue damage.
 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis 203

Fig. 16.1 Pathologic tooth migration in an old man.

204 Principles and Biomechanics of Aligner Treatment

Granulation
tissue
Gingival
enlargement

Upper lip
B
Tongue

Mastication
Occlusal forces

Lower lip

C Habits

Fig. 16.2 Pathologic tooth migration in a young woman. (A) Intraoral picture highlighting the tissue breadown.
(B) traoral picture (please note the position of element .). (C) cheme representing tissue breadown. (rom
Brunsold A. Pathologic tooth migration.  Periodontol. . doi.op.....)

A B
Fig. 16.3 Transseptal bers balance loss and pathologic tooth migration. (A) Scheme from Brnod MA ahooc
ooh mraon (B) Occa e of he aen of re  J Periodontol  do
o)
 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis 205

between specialists is mandatory, and roundtable discussion

Introduce
Preliminary discussion
complexity
is required to discuss complicated cases.1

PERIODONTAL ASSESSMENT
Comprehension
Biology ain concept orthodontic tooth movement without pree-
Interest?
Risk benefit isting inammation.
Cost eriodontitis is characteried by microbially associated,
host-mediated inammation that results in loss of peri-
odontal attachment. The bacterial biolm formation initi-
Hygiene response ates gingival inammation and promotes tissue breakdown
Therapeutic diagnosis Control phase
Compliance
Tables 1.1 and 1..
The primary goal is to eliminate periodontal disease
and stabilie the dentition. The clinical and radiologic
Interdisciplinary
assessments of the periodontal situation are mandatory be-
consultations fore treatment planning. ssessment also enables the identi-
cation of recessions, horiontal bone loss, and lesions such
Fig. 16.4 Preliminary ealuation of an orthoperio patient. (From Nanda as crater defects one-, two-, and three-wall defects and
R Esthetics and Biomechanics in Orthodontics nd ed S Lo, MO Eeer furcation defects.
) imiting factors are
n eriodontal pockets . mm
n laque inde and bleeding on probing .1
n Thin-scalloped gingival biotype
Diagnosis and Treatment Planning n iabetes out of control
n moking .1day
PATIENT EXPECTATIONS n evere tooth mobility
 very careful consideration of the patient’s chief com- rior to orthodontic treatment, the following can be per-
plaint is due in order to clearly determine the patient’s formed
needs and plan realistic treatment goals.1 These obec- n ral hygiene motivation
tives generally should be economically, occlusally, peri- n rophylais or therapy to control inammation
odontally, and restoratively realistic.1 The preliminary n urgery to eliminate deep pockets
periodontal assessment is a fundamental screening pro- n ugmentation of attached gingiva
cess during which adherence to issues of home oral n renectomy
hygiene and regular appointment attendance is deter- n limination of gingival clefts
mined ig. 1..1
t is mandatory that the orthodontist and periodontist
MULTIDISCIPLINARY TEAM discuss the management of periodontal issues and plan the
correction.
ince several skills and knowledge are needed to provide full atients with a malocclusion may present with preeist-
treatment planning, in addition to a periodontist and an or- ing mucogingival problems or fragile periodontal support
thodontist, a restorative dentist, prosthodontist, and oral or that is susceptible to attachment loss during or after orth-
maillofacial surgeon can be involved. The importance of the odontic treatment ig. 1..  proper amount of at-
team approach in achieving the best possible results in the tached gingiva is needed to dissipate the mechanical trauma
management of adult orthodontic patients with bone loss induced by mastication and tooth brushing. f teeth are
cannot be overstated. n this phase, good communication inside the alveolar ridge, predictable soft tissue grafting

Table 16.1 ramewor for taging and rading of Periodontitis

IA IT A COPIT O AAT
Stage III: Seere Stage I: danced
Periodontitis Periodontitis With
Stage II: With Potential tensie Tooth
Stage I: Initial Moderate or dditional oss and Potential
Periodontitis Periodontitis Tooth oss or oss o Dentition
idence or ris of rade A
rapid progression
rade B
anticipated treat
rade C Indiidual Stage and rade ssignment
ment response
and effects on
systemic health
206 Principles and Biomechanics of Aligner Treatment

Table 16. Periodontitis tage

PRIODOTITIS ST Stage I Stage II Stage III Stage I
Seerit Interdental  at – mm – mm  mm  mm
site o greatest loss
Radiograhic bone Coronal third Coronal third tending to tending to
loss (,) (–) midthird of root midthird of root
and beyond and beyond
Tooth loss o tooth loss due to periodontitis Tooth loss due Tooth loss due
to periodontitis to periodontitis of
# teeth  teeth
omleit ocal aimum probing aimum probing In addition to In addition to
# mm depth # mm stage II compleity stage III compleity
ostly horiontal ostly horiontal Probing depth eed for comple
bone loss bone loss  mm rehabilitation due to
ertical bone asticatory
loss  mm dysfunction
urcation econdary occlusal
inolement trauma (tooth
class II and III mobility )
oderate ridge eere ridge defect
defect
Bite collapse drifting
¤aring
, remaining
teeth ( opposing
pairs)
tent and dd to stage or each stage describe etent as localied (, of teeth inoled) generalied or molarincisor
Distribution as descritor patter

CAL, Cnca aachmen ee

Fig. 16.5 In this class II adult patient incisors are crowded etruded and proclined. oft and hard tissue grafting
can be helpful before orthodontic treatment to preent the deelopment of recessions.
 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis
Fig. 16.5, c’
procedures such as the subepithelial connective tissue graft
T and the free gingival graft  may be performed
prior to tooth movement to prevent gingival recession.
n a systematic review, loukos et al. investigated the
indication and timing of soft tissue augmentation in orth-
odontic patients. o randomied controlled trial was identi-
ed, and only limited data were available. urthermore,
osseous defects cannot allow many adult patients to clean
teeth adequately and require correction prior to or during
orthodontic therapy. These osseous defects include inter-
proimal craters; one-, two-, and three-wall defects; furca-
tion defects; and horiontal defects. nterproimal craters
are two-wall defects, where attachment loss occurs on the
mesial and distal surfaces of the adacent roots and the re-
maining walls are the buccal and lingual ones. rthodontic
movement cannot improve interproimal craters; if the
crater is mild to moderate, then resective surgery and bone
recontouring should be eecuted.
n one-wall defects, there has been destruction of three
of the four interproimal walls, leaving one wall remaining.
These defects are difcult for a periodontist to manage be-
cause resection could be too destructive and regeneration is
inappropriate. rthodontic eruption of the tooth can elimi-
nate the defect associated with occlusal reduction.
207
Three-wall defects must be treated prior to orthodontics
with regenerative therapy.  provisional splinting of the
teeth undergoing periodontal surgery is needed to provide
stabiliation. occuo et al. demonstrated that the enamel
matri derivative  alone and in association with vari-
ous grafts give the best results for the treatment of intra-
bony defects, with improvements in terms of clinical at-
tachment level  gain and pocket depth  reduction.
n this study, the orthodontic treatment was initiated  to
1 months after guided tissue regeneration T proce-
dures and aimed at correcting malposition, creating con-
tact points, and providing nontraumatic occlusion.
ince the broblastic and osteoblastic turnover is neces-
sary to heal the defect before moving the adacent teeth, the
timing of orthodontic treatment after regenerative therapy
is still debated.- an et al. recommended waiting to be-
gin orthodontic therapy until at least  months after the
completion of periodontal regenerative therapy to carry out
the movement in fully healed sites.
urcation defects are typically divided into three classi-
cations class 1, , or . lass 1 furcation defects are usually
monitored during orthodontic therapy. lass  and  furca-
tion defects should be treated by the periodontist before
the orthodontic treatment to allow a proper hygiene.
20 Principles and Biomechanics of Aligner Treatment

ometimes, if the periodontal health of adacent teeth can n void ecessive ridge epansion.
be maintained, hopeless teeth are used during orthodontic n void ecessive proclination.
treatment to provide anchorage and occlusal function for
the patient. very orthodontic tooth movement beyond the cortical
The orthodontist must evaluate the horiontal bone loss plate should be avoided. ingival recessions can be related
because there is an alteration of crownroot ratios. f hori- to ecessive epansions and movements outside the alveo-
ontal bone loss has occurred in only one area, reduction of lar bone housing i.e., when an alveolar bone dehiscence
crown length will avoid the creation of bony defects has been created ig. 1.. anarsdall suggested that
between adacent teeth after leveling. patients with a transverse skeletal maillomandibular dis-
uring orthodontic treatment, the following can be crepancy greater than  mm are susceptible to recessions,
performed especially if palatal epansion is needed. ith the intro-
duction of three-dimensional  imaging in orthodon-
n rophylais and plaque removal every month to control
tics, a diagnosis in three planes of space can be obtained
inammation
with relative ease and minimal radiation.
n urgical eposure of impacted teeth according to peri-
n a recent study on adolescent patients, an evaluation
odontal concepts
using cone-beam computed tomography T scans be-
n ibrotomy every 1 days during forced eruption
fore and after orthodontic alignment stated that bone
fter orthodontic treatment, the following can be thickness T decreased and height from the cementoe-
performed namel unction to the alveolar crest  increased signi-
cantly for the incisors and mesiobuccal root of the rst
n upportive therapy
molars. rch dimensions generally increased together
n linical crown lengthening
with tipping, and epansion related to alignment resulted
n ingivoplasty
in horiontal and vertical bone loss at the incisors and me-
n oot coverage
siobuccal root of the rst molars. Thinner Ts and more
severe crowding before treatment increased the risk for
ORTODONTIC ASSESSMENT DETERMINATION buccal bone loss. s etraction may worsen the soft tis-
OF FINAL OCCLUSION sue prole, especially in adult patients, protraction of the
lower incisors is an alternative dealing with cases of lower
ental history in adult patients should not be overlooked crowding or increased overet.  benecial effect on the
and, along with restorative requirements, is a key factor in soft tissue prole through smoothing of the mentolabial
determining the nal occlusion.  specic evaluation of sulcus can be achieved, but the optimal position of the
parafunctional habits, temporomandibular disorders, lower incisors is still not clear.
cracked teeth, and wear facets is mandatory Table 1.. o association between proclination and gingival re-
articular focus is on the following cession has been found by rtun and robéty, while
n Tooth movements within bone limits others consider lower incisor proclination a risk. ied-
n val-shaped roots buccolingual dimension wider than rich stated that the specic anatomy must be taken into
the mesiodistal dimension consideration, such as the gingival health and the force
n resence of fremitus system.
n valuation of tongue pressure The morphology of mandibular anterior alveolus differs
in hypodivergent, hyperdivergent, and norm divergent pa-
tients, but the evaluation of symphysis morphology on
CONSIDERATIONS cephalometric radiographs might not be a solid method
n valuate teeth with intact or reduced periodontal support. aimed at predicting gingival recession in the anterior region
n revent plaque buildup avoid ed appliances. of the mandible. The relationship between periodontal
status of mandibular incisors and selected cephalometric
Table 16. Orthodontic oements And alocclusion
parameters has recently been investigated the width of
eatures keratinied gingiva T was found to correlate with
, T, and symphysis length, while gingival thick-
Issues oals ness T was associated with T and symphysis length.
Crowding Alignment oth T and T are regarded as signicant risk factors
for gingival recession.
laring Closure of diastemas and
retraction intrusion n a recent study, no higher occurrence of gingival re-
cession in cases of pronounced proclination of lower inci-
Blac triangles eshaping by interproimal
reduction retraction intrusion sors without violating the osseous envelope of the alveolar
process has been found. t can be speculated that if the
Bone peas and gingial Intrusionetrusion
margins need leeling gingiva maintains appropriate thickness, it is more resis-
tant and less affected by tension from large proclination.1
emoal of occlusal etraction and intrusion selectie
interference grinding n a retrospective study, elsen found that gingival reces-
sion on mandibular incisors was not signicantly increased
ornlost teeth Prosthetic rehabilitationspace
closure during orthodontic treatment. Thin gingival biotype, visual
plaque, and inammation are useful predictors of gingival
Preention of relapse etention
recession.
 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis
Fig. 16.6 In this adult patient a preious ecessie orthodontic epansion promoted a gingial recession on
teeth  and . The occlusal instability has led to orthodontic relapse.
Teeth can be moved with their surrounding periodon-
tium when careful attention is paid to local anatomy and
periodontal health. urthermore, tooth movement with
or through bone can be provided using different force
systems. hen an optimal oral hygiene has been
achieved, it is possible to apply orthodontic forces, even
if the periodontal tissue has reduced connective tissue
attachment and alveolar bone height., Traditional
ed orthodontic appliances induce microbial changes
toward periodontopathogenic anaerobic bacteria because
of the increased plaque accumulation. These effects
are normalied after removal of orthodontic appliances
without lasting detrimental effects, but in some patients
there is a signicant risk for irreversible periodontal
destruction. Thus the use of clear aligners that promote
a better periodontal health when compared to ed
appliances- may be the optimal choice in patients
with periodontal involvement. ith clear aligners, it is
possible for good control of oral hygiene throughout
treatment, while the rst months with ed appliances
are always difcult to manage.1
The forces and moments generated by aligners of the
nvisalign system are always within the range of orth-
odontic forces. The forces and couples delivered by align-
ers are determined by the shape of the crown and the type
and amount of displacement of the particular tooth and
therefore the contacts between tooth and the inner surface
of the appliance. Tipping movement is predictable with
20
thermoplastic appliances, but difculties about root con-
trol have been reported.
ince the gingival margin of the aligner is elastic, it is not
surprising that an aligner would have difculty controlling
the forces applied in this region. The introduction of ower
idges demonstrates that when a torque correction of
about 1 degrees is required, torque loss is negligible. The
force couple generated by a thermoplastic aligner torquing
an upper incisor consists of a tipping force near the gingival
margin and a resulting force produced by movement of the
tooth against the opposite inner surface of the appliance,
near the incisal edge. The undesirable mesial movement
of rst molar compensation requires programmed forward
mesial root rotation, in effect producing crown tipback
rotation.
n an in vitro study, imon et al. investigated the
influence of auiliaries, such as attachments and ower
idges, on performing root movements of upper central
incisor torque.  loss of torque up to  must be con-
sidered; however, it must be noted that the efficacy of
fied orthodontic appliances does not reach 1 ei-
ther. onventional orthodontic brackets and wires do
not completely fill the bracket slots so that the wire is
able to twist, leading to a loss of moment known as
torque play. The loss of torque between an arch of .1
3 . in. section usual sie for the final stages of
orthodontic treatment and a . 3 . in. slot is
about 1 degrees.
210 Principles and Biomechanics of Aligner Treatment
 more recent study stated that nvisalign is able to
achieve predicted tooth positions with high accuracy in
nonetraction cases. ombardo et al. stated that some
tooth movements can be achieved with aligners more eas-
ily than others. n particular, vestibulolingual tipping and
rotation reached . and . of the prescribed
movement, respectively. n a retrospective study, fondrini
et al. found no differences between aligners and brackets
about buccolingual inclination control on upper incisors.
These studies led to different conclusions probably be-
cause of the development and improvements in materials,
technologies, and treatment protocols. everal factors are
involved in determining successful tooth movement the
attachment’s shape and position, the aligner’s material
and thickness, the amount of activation present in each
aligner, and the techniques used for the production of the
aligners.
Treatment outcomes depend also on the patient’s character-
istics, bone density and morphology, crown and root morphol-
ogy of teeth, as well as on factors related to the clinician such
as the accuracy in performing the requested amount of inter-
proimal reduction , which is usually underestimated.
The plastic foil used for the fabrication is thinned out by
thermoforming at the gingival edge of the aligners, thus
representing the area where they are less rigid. urther-
more, to avoid loss of anchorage, simultaneous movement
of multiple teeth should not be performed.
lanning clear aligner therapy T with virtual setup
software facilitates choosing an appropriate number of an-
chor teeth and the proper sequence of tooth movement to
minimie the risk of anchorage loss.1 owever, an aligner
alone cannot provide proper anchorage control, especially
in situations in which tooth morphology is not favorable
i.e., small clinical crowns, reduced undercuts. To over-
come clear aligner limitations, the development of effective
attachments rectangular and vertical, for both anchorage
management and better root control, is increasing. The use
of conventional bulk-ll resins for the attachment creation
leads to a higher precision.
The  planning, especially when associated with T
data, can allow a proper control; moreover, the velocity of
movements can be selectively slow .1 mm g1 days.
 T eamination is useful to evaluate the spatial
position of the teeth within bone. They may be positioned
off-ais and present radiographically with fenestrations and
dehiscences. nticipated orthodontic treatment can
improve tooth position in the bone so that mucogingival
deciencies can be subsequently reevaluated ig. 1..
n periodontal patients there is interproimal bone loss, and
the periodontal obectives are more valuable than the occlusal
ones. The role of the orthodontist should be leveling the bone
peaks. The marginal ridges are not always helpful for position-
ing the posterior teeth. f they are worn or abraded, it is more
important to nd the best position to facilitate restoration.
Tooth shape is another factor with great importance in
treatment planning. n the maority of patients, we nd
three main tooth shapes rectangular, triangular, and bar-
rel-shaped teeth. specially when the crown has a triangu-
lar shape, the distance between the bone crest and the
contact point is relatively large, and the interproimal pa-
pilla tends to be absent. Tarnow demonstrated that the
papilla is present in 1 of cases when the distance from
the contact point to the interdental bone crest is  mm or
less. ince adults have narrower pulp chambers,  can
be performed and black triangles closed ig. 1..
Orthodontic Moements
ith a healthy periodontal tissue, the supracrestal bers
control the etrusive component of forces applicated hori-
ontally to teeth. hen the bone support is reduced,
forces are distributed over a smaller area, and the resis-
tance to etrusion is lower. urthermore, the center of
resistance of a periodontally involved tooth is shifted api-
cally because of the bone resorption. That is why occlusal
forces induce tipping and etrusion of the incisors. hen
planning the orthodontic treatment, the apical displace-
ment of the center of resistance should be taken into
account, and the moment-to-force ratio therefore must
be adapted to the individual situation igs. 1.
and 1.1.
To provide a uniform loading on periodontal ligament,
translation and controlled tipping movements should be
preferred. The orthodontic treatment with clear aligners
in periodontal patients should be similar to the segmented
arch approach. The active and reactive units should be
identied and force delivery planned .
OPTIMAL CONTROL OF IOMECANICS
n se of light forces
n enter of resistance
n void roundtrip
n low movements
n elective movements
n eed for further anchorage implants, temporary an-
chorage devices Ts free anchorage lost teeth
Taking the tooth long ais as a reference, three kinds of
movement can be performed.
Mii M
esiodistal movements are mainly used to close diastemas
and eliminate the black triangles, after providing  and
the creation of a surface of contact. pace opening for
implant placement is a predictable movement that can be
carried out both in anterior and posterior regions. urgi-
cal bone augmentation could be needed at the end of ortho-
dontics due to high interindividual variability of neoformed
bone thickness.
 mesially inclined molar is not a cause of periodontal
disease itself; however, molars uprighting alone can be
performed to achieve root parallelism before implant place-
ment. n presence of an infraosseous defect, T should
be eecuted prior to orthodontics.  strict control of oral
hygiene on the distal side of an uprighting tooth is manda-
tory to avoid subgingival plaque formation. dditional an-
chorage using miniscrews may be needed in case of tricky
malpositions. The mesialiation of molars is a translation
movement that can be performed using light forces
ig. 1.11; however, considering the high risk of compli-
cations such as bone fenestration, bone loss, and radicular
resorption, it should be managed carefully.
16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis 211

Fig. 16.7 Orthodontic relapse in a young patient teeth   and
 are located outside the buccal bone. The twisted retainer prob
ably not passie allowed a radicular torue moement  on tooth
 that promoted a gingial recession with lac of adherent gingia.
212 Principles and Biomechanics of Aligner Treatment

Fig. 16. ifferent tooth shapes. (From Nanda R Esthetics and Biomechanics in Orthodontics nd ed S Lo, MO
Eeer )

Fig. 16. Center of resistance ariation in case of bone loss. (From Nanda R Esthetics and Biomechanics in
Orthodontics nd ed S Lo, MO Eeer )

Fig. 16.10 In this patient a stainless steel powerarm has been bonded
to tooth  and retraction has been performed using maimum
anchorage. Fig. 16.11 esialiation of lower third molars.
 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis
iig M
estibulolingual movements are needed to position teeth in-
side the alveolar bone. fter a proper evaluation of bone
thickness, typical localied recessions on incisors can be im-
proved through retraction of teeth within the alveolar walls.1
The most effective movements, translation and lingual
root torque, must be carried out on lower incisors only after
a previous evaluation of mandibular symphyseal dimensions
height, depth, and angle. rthodontics can be subsequently
followed by mucogingival surgery for complete root covering.
n selected cases, bodily movements can be associated
with corticotomies and bone tissue grafting to prevent fur-
ther periodontal damage. n efcient torque control is
also needed, in combination with intrusion, during retrac-
tion of ared incisors after pathologic tooth migration.
ic M
The vertical movements are the main issue in periodontal pa-
tients since they are used to restore the correct alveolar bone
and gingival margin levels. oving a tooth with a vertical de-
fect can increase the risk of further attachment loss. f intru-
sion is needed, the probing depth has to be reduced before or-
thodontics. Three-wall defects can be successfully treated with
regenerative surgery followed by orthodontic intrusion.
ntrusion is indicated when vital teeth are etruded, in
both anterior and posterior regions. n an animal study,
elsen demonstrated that intrusion can improve the quan-
tity of new attachment if carried out under healthy condi-
tions.  proper intrusive force should be  to  g per tooth
and is affected by the periodontal support. efore providing
Fig. 16.12 electie intrusion of worn teeth. (From Nanda R Esthetics and Biomechanics in Orthodontics nd ed
S Lo, MO Eeer )
213
vertical movements, a correct diagnosis should take into ac-
count the presence of recession and the labial sulcular depth
of the maillary incisors. f no recession has occurred, the
gingival margins are used as a guide in tooth positioning.
f the sulcular depth is uniformly 1 mm, the discrepancy
in gingival margins may be due to uneven wear or trauma
of the incisal edges ig. 1.1. Treatment for this problem
is the intrusion. hen the gingival margins are aligned, the
discrepancy in the incisal edges presents itself, and restora-
tion of the short teeth can be provided.
rthodontic intrusion should be planned to also properly
treat lower incisors with incisal edge abrasion. These teeth
typically are overerupted to maintain contact, and no space
for restoration is left. ndodontic treatment and periodontal
crown lengthening with bone removal are avoided by ortho-
dontics that provides the correct restorative space.
eriodontal patients are usually characteried by ared and
etruded upper incisors and horiontal bone loss.11  combina-
tion of retraction and intrusion is needed, while a simple retro-
clination would deepen the bite. The available molars and pre-
molars are used as anchorage units. dditional scaling and root
planning every  weeks are mandatory during active intrusion.
espite contrasting evidence about intrusion in patients
with reduced periodontal support, elsen found creation
of new attachment with a consequent reduction of root to
crown ratio and ardaropoli et al.  demonstrated the
reduction of probing pocket depth and the gain of clinical
attachment after combined ortho-perio treatment of
etruded teeth with infrabony defects. The use of light
1– g and continuous forces together with proper
214 Principles and Biomechanics of Aligner Treatment
torque control seems to be relevant.-1 evertheless, there
can be transformation of supragingival plaque in subgingi-
val and risk of angular defect formation. oreover, atten-
tion must be paid to root morphology, since there is a higher
risk of resorption of short and pipette-shaped roots.
hen a periodontally involved tooth needs prosthetic reha-
bilitation or the gingival margin is more apical than the others,
orthodontic etrusion has a benecial effect on the bone level.
trusion movements can be eecuted to level gingival margins,
recover the interdental papilla, and reduce probing depth. -
trusion can be performed either with light or heavy forces.
undamentals are direction of movement and torque control
because uncontrolled tipping can lead to vestibulariation of the
root.  constant occlusal grinding is due to avoid premature
contacts. t the end of the movement, a ed retention should
be performed for at least  months to prevent relapse.
n case of healthy periodontium, when the crown is lost
because of decay or trauma, etrusion is performed associated
with brotomy every 1 days or followed by surgical crown
lengthening. n case of attachment loss, etrusion is ee-
cuted to level gingival margins and reduce angular defects.
llow  to  months for connective bers to heal after regen-
erative therapy.  single compromised tooth can be etruded
for leveling of gingival margins, providing hard and soft tissue
augmentation before the implant placement. n this case, the
use of light forces 1 mmmonth is recommended.
f a patient is missing multiple teeth, treatment plans can
eventually include placement of dental implants to have a
further anchorage for the orthodontics. efore the orth-
odontic loading, a proper amount of time is needed for the
osteointegration. Ts such as microscrews and bone
plates are also effective in enhancing tooth movements
without the biomechanical side effects.
FINAL FLOCART
n eestablish periodontal health
n eriodontal reassessment
n f possible, regenerative andor mucogingival surgery
and implant placement
n rthodontic treatment
n eriodontal maintenancesupportive therapy
n rthodontic retention
n rosthodontic naliation
Retention
educed periodontal tissues are a risk factor for orthodontic
relapse. n addition, the periodontally involved teeth
could be signicantly mobile. The purpose of retention is to
stabilie them and reduce mobility. very action that in-
tends to prevent relapse should be performed immediately
after the completion of orthodontic movement.
ince the presence of retainers bonded to all anterior teeth can
increase plaque accumulation and gingivitis, the use of remov-
able retainers should be recommended when ecessive mobility
is not an issue. oreover, ed retainers can produce inadver-
tent tooth movement, and regular observation is needed. ara-
functional habits, such as onychophagia, might be involved.
The orthodontic patient with periodontal involvement may be
missing one or more teeth. ince pathologic tooth migration is
worsened by lack of posterior occlusal support, a nal prosthetic
rehabilitation should always be planned.  ed or removable
prosthesis can help stabilie the remaining teeth in the arch and
provide an occlusal stop for teeth in the opposing arch.
cclusal splint, can be eventually used as orthodontic
retention in patients with parafunctional habits, including
n emovable retainers
n hen mobility is ecessive
n ower ed retainer -, - in case of deep bite
n ntra- or etracoronal ed retainer in other setant
n rosthetic rehabilitation of edentulous sellae
n cclusal night guard
onclusions
lear aligners are safer than conventional orthodontics for
stable periodontal patients. ligners allow patients to have
ecellent hygiene control, especially during long treatments.
linheck software is a diagnostic tool that provides a virtual
setup both for orthodontics and prosthodontics. t offers a pre-
cise  plan control of each movement and the possibility of
selective anchorage. The keys to success are based on both
lifelong supportive periodontal treatment and orthodontic re-
tention. atient adhesion to the supportive periodontal treat-
ment is mandatory to maintain stable long-term results.1-
linical ase
FIRST ISIT
ate 1--1
ender ale
ge y
rofession mployed
hief complaint leeding gums and drifting of front teeth
ttitude atient is concerned about his dentition and is
positive about keeping his teeth
pectations atient has realistic epectations and wants
to restore his dentition in health
edical anamnesis
eneral appraisal of patient it and healthy
amily medical anamnesis
ast pathologic anamnesis ypertensive
ecent pathologic anamnesis one
rug therapy
llergies or sensitivities one
abits ormer smoker who quit  months back
ccupation and stress level mployed in a multinational
company; medium stress level
ast physical eamination  months back, nothing signicant
ental anamnesis igs. 1.1 and 1.1
ate and reason for the last dental visit  months back for
bleeding gums
aor dental treatments o
issing teeth reason 1. caries
dverse dental eperiences one
istory of periodontal disease es
revious periodontal treatments nly supragingival scaling
ral habits one
ral hygiene practices rushes twice daily with a manual
toothbrush
rophylais frequency nce every year
T and muscles of mastication oth unremarkable
 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis 215

Fig. 16.13 Baseline intraoral iew.

INTRAORAL CLINICAL EXAM

ental analysis
n ngle class olar and canine class 1
n issing teeth 1.
n ental malpositions 1.1 etruded and proclined
n ecays one
n nadequate restorations . premature contacts in

centric occlusion one

n cclusal trauma one
n cclusal wear one

orking contacts on right side 1. canine guided

ig. 1.1
Fig. 16.14 Baseline smile. n alancing contacts on left side one
216 Principles and Biomechanics of Aligner Treatment

Fig. 16.15 oring contacts.

orking contacts on left side . canine guided

n alancing contacts on right side one n nterradicular translucencies one
rotrusive contacts 1.1, 1. n amina dura and periodontal ligament enlargements
n osterior interferences ., . one
n eriapical pathologies one
XRAY STATUS
n etained teeth one
n oot fragmentsforeign bodies one
n mount of bone resorption  bone loss vertical and n ecays one
horiontal ig. 1.1 n evitalied teeth one

Fig. 16.16 Baseline status.

 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis 217

ASELINE PERIODONTAL CART (I. .)

Fig. 16.17 Baseline periodontal chart.

21 Principles and Biomechanics of Aligner Treatment

PERIODONTAL REEALUATION (I. .

PERIODONTAL EXAMINATION and .)
n. teeth  DIANOSIS
n. teeth with   mm 
 eneralied chronic severe periodontitis level  presence of
n # mm  proimal attachment loss of  mm in two or more non-
n – mm  adacent teeth
n  mm 1 tage  grade  Tables 1. and 1.

Fig. 16.1 eealuation chart.

 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis 21

B
Fig. 16.1 (A) Toothbytooth diagnosis. (B) Toothbytooth prognosis. (From Ko V, Caon  Commenar
rono reed a em for ann erodona rono J Periodontol )

Table 16. tages of Periodontitis

PRIODOTITIS ST Stage I Stage II Stage III Stage I
Seerit Interdental  at – mm – mm  mm or etending  mm or etending to the
site o greater loss to the middle third of apical third of the root
the root
Radiograhic Coronal (,) Coronal third tending to middle tending to the apical third
bone loss (–) third
Tooth loss o tooth loss due to periodontitis Tooth loss due to peri Tooth loss due to periodonti
odontitis of # teeth tis of  teeth
omleit ocal n aimum n aimum In addition to stage II In addition to stage III
probing depth probing depth compleity compleity
of – mm – mm n Probing depth n eed for comple rehabili
n ostly n ostly  mm tation due to masticatory
horiontal bone horiontal bone n ertical bone loss dysfunction
loss loss  mm n econdary occlusal trauma
n urcation (tooth mobility degree )
inolement n Bite collapse
n Class II or III n rifting
moderate ridge n laring
defect n , remaining teeth
n eere ridge defect
tent and dd to stage as or each stage describe etent as localied (, of teeth inoled) generalied or molar incisor pattern
Distribution descritor

CAL, Cnca aachmen ee

220 Principles and Biomechanics of Aligner Treatment

Table 16. rades of Periodontitis

rade  rade  rade 
Slo Rate Moderate Rate Raid Rate
PRIODOTITIS RD o Progression o Progression o Progression
Primar riteria irect eidence of ongitudinal data idence of no loss , mm oer  mm oer  years
progression (PA radiographs or oer  years  years
CA loss)
Indirect eidence of Bone lossage ,. .–. ..
progression
Case phenotype eay biolm estruction estruction eceeds
deposits with low commensurate epectation gien
leel of destruction with biolm biolm deposits specic
deposits clinical patterns sugges
tie of periods of rapid
progression andor early
onset disease lac of
epected response to
standard bacterial
control therapies
rade Modiers is factors moing onsmoer moer , moer  cigarettes
cigarettesday day
iabetes iabetes ormoglycemic bAc ,. in bAc . in diabetes
with or without prior diabetes patients patients
diagnosis of diabetes

CAL, Cnca aachmen o PA, eraca HbA1c, refer o caed haemoon

PERIO TREATMENT OALS n sseous resective surgery with tunnel preparation .
n upportive periodontal treatment
1. ontrol of supragingival and subgingival infection
.  , Oic
. rrest of the progression of periodontitis
lignment and space closure on upper arch
. traction of hopeless teeth
I T
TREATMENT PLAN n 1., 1., .

tiologic therapy Pi Si T

1. ral hygiene instructions and motivation very  months igs. 1.1 through 1.
. onsurgical therapy caling and root planing quad- The periodontal therapy was performed by rof. ario
rant by quadrant protocol imetti, head of the epartment of eriodontology of the
. traction of 1., ., . ental chool of the niversity of Torino, Torino, taly.
. hange of lling ., .
Oic Digi (ig. .)
CLINICAL EXAMINATION REEALUATION keletal
n   1,  
(I. .) ental
n. teeth  n olar  nonassessable, canine  1, deep bite,

n. teeth with   mm  increased , spaces between teeth and black
 triangles, medial line deviated
n # mm 1 acial
n – mm  n onve prole

n  mm 
Scic Oci  T igs. .
through .)
TREATMENT PLAN AFTER ETIOLOIC TERAPY n ailla lign and intrude the teeth, close spaces, cor-
n egenerative therapy 1., etraction 1., 1. rect the midline
n egenerative surgery 1.1, 1., . n andible lose spaces, intrude lower incisors, correct
n traction ., mesial root resection . the midline
n egenerative surgery ., . n acial esthetics mprove esthetic smile line
 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis 221

Fig. 16.20 Periodontal status and chart at reealuation.

222 Principles and Biomechanics of Aligner Treatment

3 mm 3 mm 3 mm 3 mm

3 mm 4 mm 8 mm 3 mm

B C
Fig. 16.21 egeneratie therapy on tooth . (A) Bone sounding (B) incisional photos (C) ¤ap photos.
 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis 223

A B

C D
Fig. 16.22 egeneratie therapy on tooth  biomaterial photos. (A) efect cleaning. (B) mdogain (s).
(C) Pref el (TA). () BioOss.

Fig. 16.23 egeneratie therapy on tooth suture photos.

224 Principles and Biomechanics of Aligner Treatment

A B
Fig. 16.24 egeneratie therapy on incisors. (A) Incision pfotos and (B) ¤ap photos.

A B

C D
Fig. 16.25 egeneratie therapy on incisors biomaterial photos. (A) efect cleaning. (B) mdogain (s).
(C) Pref el (TA). () BioOss.
 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis 225

Fig. 16.26 Osseous resectie surgery degree setant.  Alternatie therapies periodontal supportie
therapy   conseratie surgery resectie bone surgery.
226 Principles and Biomechanics of Aligner Treatment

Fig. 16.27 esectie surgery bone remodeling.

Fig. 16.2 Orthodontic records.

 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis 227

A B
Fig. 16.2 ClinChec beginning (A) and end (B) frontal iew.

A B
Fig. 16.30 ClinChec beginning (A) and end (B) upper arch.

A B
Fig. 16.31 ClinChec beginning (A) and end (B) lower arch.
22 Principles and Biomechanics of Aligner Treatment

A B
Fig. 16.32 ClinChec beginning (A) and end (B) right side.

A B
Fig. 16.33 ClinChec beginning (A) and end (B) left side.
 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis 22

Fig. 16.34 nd of preprosthetic orthodontics.

Fig. 16.35 Implant . ..

230 Principles and Biomechanics of Aligner Treatment

Fig. 16.36 Implant placement.

Fig. 16.37 Implant placement photos.

 16 • Clear Aligner Orthodontic Treatment of Patients with Periodontitis 231

A B

C D
Fig. 16.3 Implant placement biomaterials. (A) Bony window. (B) inus membrane eleation. (C) BioOss.
() BioOss and membrane positioning.

Fig. 16.3 inal orthodontic rays.

Continued
232 Principles and Biomechanics of Aligner Treatment
Fig. 16.3, c’
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. othe , ollen , ittle , et al. Trabecular and cortical bone
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. kantidis , hristou , Topouelis . The orthodontic-periodontic
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. haughnessy T, roft , amar . nadvertent tooth movement
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. alvi , ischler , chmidlin . isk factors associated with the
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1-.
. ee T, uang , un T, et al. mpact of patient compliance on
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1..
. arnevale . ibre retention osseous resective surgery a novel
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;1-1. doi1.1111.1-1..1..
. envert , ersson .  systematic review on the use of residual
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1;1-. doi1.1op.1....1.
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.1..
1. eit-ayeld , Trombelli , eit , et al.  systematic review of
the effect of surgical debridement vs non-surgical debridement for
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;-1. doi1.1.1-1..s...
11. Trombelli , arina , ranceschetti , et al. ingle-ap approach
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 17 Surgery First with
Aligner Therapy
FLAVIO URIBE and RAVINDRA NANDA
HISTORIC BACKGROUND
The treatment of moderate to severe dentofacial deformity is
usually addressed by means of orthognathic surgery. The ob-
jectives of orthognathic surgery are to accomplish adequate
facial esthetics while achieving a functional occlusion. The
occlusal relationship serves as a guide for the skeletal move-
ments and therefore is an important element in orthognathic
surgery. Fixed orthodontic appliances in the presurgical phase
have historically been used to prepare the dentition for the
skeletal movements and to ne-tune the occlusion after or-
thognathic surgery. pecically labial xed appliances in the
presurgical phase eliminate dental compensations and pre-
pare the arches for surgery. onded orthodontic brackets on
the labial surfaces of the teeth and wires are the orthodontic
appliances of choice by clinicians in orthognathic surgery as
treatment complexity is high in these patients.
lear aligner therapy T with nvisalign lign Tech-
nologies an ose   at the forefront has become a
treatment modality in orthodontics that has gained accep-
tance by practitioners after the signicant improvements in
the appliance over the last few years. ore complex maloc-
clusions have been able to be treated with this appliance with
the addition of attachments that optimie tooth movements.
n example of more complex approaches with the nvisalign
appliance is evident in its use in tandem with orthognathic
surgery instead of the conventional labial xed appliances.
rthognathic surgery in conjunction with the nvisalign
appliance is well accepted by patients with dentofacial defor-
mity for two main reasons. First most of these patients are
usually adults who understandably favor the inconspicuous-
ness of clear aligners over xed labial appliances. econd
often patients undergoing orthognathic surgery have re-
ceived orthodontic treatment with xed appliances during
their early teenage years. This treatment has usually been
long as the orthodontic therapy may have tried to camou-
age the effects of abnormal growth. The net effect is a burn-
out of the patient who does not want to receive any more
orthodontic therapy.
rthognathic surgery has three specic stages which
include a presurgical orthodontic phase the surgical proce-
dure and a postsurgical orthodontic nishing phase. The
incorporation of nvisalign in orthognathic surgery can be
accomplished in different ways depending on which stage
of treatment it will be used and the type surgical approach
surgery rst or conventional approach. For example one
of the approaches is to limit the nvisalign appliance to the
presurgical phase. Typically this phase is the longest in or-
thognathic surgery lasting approximately from  to 
months. Therefore if patients receive T on the
presurgical phase xed appliances will be only used for a
short period of time during the postsurgical phase. This ap-
proach is often preferred since the labial xed appliances
used in the postsurgical phase typically have better nish-
ing control of the occlusion. The labial orthodontic appli-
ances are placed just before surgery thereby facilitating the
conventional approach during surgery that ties the interoc-
clusal surgical splint to the orthodontic bonded appliances
required for xation of the proximal and distal bone seg-
ments after the osteotomies. The second approach uses the
nvisalign system for both pre- and postsurgical phases
with no xed labial appliances which has the challenge of
limited areas available to securely tie the surgical splint for
maxillary and mandibular xation.
lthough clinicians are using nvisalign in conjunction
with orthognathic surgery no studies have been conducted
evaluating the outcomes with this approach. n fact most
of the published literature has been in the form of case re-
ports. The rst report of this approach was published in
 using nvisalign in combination to orthognathic sur-
gery. The treatment of two patients was described in which
nvisalign was used for the presurgical phase of aligning
and leveling the arches. egmental xed appliances were
also used as adjuncts to the clear aligners to derotate some
teeth since at that point in time the nvisalign appliance
had not developed the optimied attachments that facili-
tated these corrections. Fixed appliances were placed just
before the surgical procedure and maintained through the
postsurgical detailing phase. The total treatment time for
one patient was  months  months for the presurgical
phase with nvisalign and  months for the other 
months for the presurgical phase with nvisalign. The rea-
son for one of the patients having undergone almost 
years of treatment was attributed to insurance approval
and scheduling the surgery date. dditionally the patients
were changing aligners every  weeks. Finally the author
suggested that in patients with single jaw surgery xed ap-
pliances would not be necessary being managed fully with
the nvisalign appliance.
n  omack and ay reported on another patient
treated with nvisalign and orthognathic surgery who had
class  malocclusion and sleep apnea. n this report bimax-
illary advancement with a two-piece-maxilla for transverse
correction was executed. oth the pre- and postsurgical
phases were completed with the nvisalign appliance. The
duration of the presurgical phase was  months for this
patient. The xation during surgery of the maxilla and the
mandible after the osteotomies was achieved by means of
archbars tied to the splint. ince the maxilla was split for
transverse expansion a soft tissue splint was placed during
235
236 Principles and Biomechanics of Aligner Treatment
surgery and left for  weeks for stabiliation of the two max-
illary halves. fter the surgical procedure polyvinyl silox-
ane  impressions were taken for renement of the oc-
clusion which took another  months of treatment. The
total treatment time was  months which included a pe-
riod in which the patient was not seen due to unavailability
related to a work schedule. uring this nishing phase but-
tons were bonded to the posterior teeth to settle the occlu-
sion with elastics.
ancui et al. in  reported on the treatment of a
patient who had multiple missing teeth and class  maloc-
clusion who underwent orthognathic surgery with nvis-
align. oth pre- and postsurgical phases were performed
with the nvisalign appliance. The presurgical phase lasted
 months. For the xation of the maxilla and mandible into
their new positions buttons were bonded to the labial sur-
faces of the majority of the posterior teeth. The authors
maintained the patient on the splint for  weeks after sur-
gery and then delivered a dynamic functional positioner for
 months. ome ceramic brackets were bonded to help with
the seating of the occlusion. The total treatment time was
 months.
agani et al. in  reported on another patient with a
class  malocclusion treated with nvisalign in the pre-
and postsurgical phases.  total of  months was the du-
ration of the presurgical alignment phase. The day before
surgery xed appliances were bonded which were removed
 month after surgery. The total duration of treatment was
 months.
Fig. 17.1 Surgical splint with holes to be used in a patient undergoing orthognathic surgery using Invisalign as the
only appliance for orthodontic treatment. Note that no labial orthodontic appliances are present.
Splint-Aided Maxillary and
Mandiblar ixatin itt
abial ixed Appliane
hen labial xed orthodontic appliances are not present
the stabiliation of the surgical splint after the osteotomies
can be troublesome. The maxilla and mandible need to be
securely tied to the surgical splint to ensure proper refer-
encing the jaws to each other to achieve the planned out-
come after surgery. The surgical splint transfers the infor-
mation of the virtual three-dimensional  plan to guide
the free osteotomied segment to a stable reference skeletal
region. The splint must be tied to the dentition or denture
bases to reference maxilla and mandible to each other. The
connection of the splint to the teeth is usually facilitated
when orthodontic appliances are bonded to the labial sur-
faces of the teeth. ith nvisalign there are no labial appli-
ances to enable this connection Fig. .. ifferent ap-
proaches have been described in the literature to overcome
this problem. rchbars used for maxillary and mandibular
fracture xation are one of the earliest adopted approaches.
The problem with this approach is it is time consuming
thereby extending the duration of time the patient is under
anesthesia which increases the risks of the surgical proce-
dure. nother approach is to bond multiple buttons on the
labial surfaces of teeth specically to be used for the surgi-
cal procedure. This was reported by ong et al. when using
lingual orthodontic appliances in orthognathic surgery.

owever since no archwires are present connecting the
bonded buttons bonding failure could occur during the
operation while the jaws are being tractioned to seat them
into the splint. Furthermore the breakage of one of these
attached buttons may end up entrapped in the mucoperios-
teal aps causing a signicant complication to the surgical
procedure.
ith the advent of miniscrews in orthodontics the con-
nection of the dentition to the surgical splint has been fa-
cilitated. This was reported by aik et al. who added two
miniscrews in each of the quadrants mesial to the rst
molars and premolars. These miniscrews are used to secure
the splint tightly to the teeth and can be used after surgery
to support the use of intermaxillary elastics to keep the
teeth in the postsurgical planned occlusion.  more com-
plex setup that connects the miniscrews through a bar
framework is commercially available. The martlock hy-
brid F from tryker alamaoo   and the a-
trix F from epuy ynthes raniomaxillofacial
est hester   are similar bone-supported arch-
bars to be used during surgery. This framework is secured to
the labial alveolar bone of the dentition through four to six
miniscrews per arch. The main advantage of these two
products over an approach that uses only the miniscrews is
that more locations are available to connect the surgical
splint to the maxilla and mandible through ligatures. This
may facilitate more tight adaptation of the osteotomied
segments into the surgical splint. Typically the mesh in-
cluding the miniscrews is removed after the osteotomied
maxilla and mandible are secured with hardware which
has the drawback that intermaxillary elastic wear in the
postsurgical stage will require to be delivered from the
teeth which could have an unfavorable extrusive effect on
the specic teeth from which the elastics are being worn.
Tranitinin Int and Ot
 Srery it Clear Aliner
s mentioned the major difference in the execution of sur-
gery in patients with T is the absence of labial xed orth-
odontic appliances typically necessary for securing the sur-
gical splint. These patients are typically wearing a series of
sequential aligners as part of the presurgical phase and will
transition to the aligners in the postsurgical phase to com-
plete orthodontic treatment. f the patient is wearing align-
ers in the presurgical phase the surgical plan will consist of
maxillomandibular movements that will achieve a result
close to the nal idealied occlusion. rior to surgery a scan
or impression is taken to plan the tooth movements after
surgery to detail the occlusion which will be used for fabri-
cation of the aligners. n alternative is to take this scan or
 impression after surgery. owever the acquisition of a
scan or impression after surgery is somewhat difcult due
the limited mouth opening observed during the rst 
months after surgery. Therefore taking the scan prior to
surgery may be advocated to be able to start wearing the
aligners soon after surgery approximately  weeks after.
lthough this approach may expedite treatment there still
may be a slight unpredictability in the planned occlusion
and the actual postsurgical occlusion if different may
17 • Surgery First with Aligner Therapy 237
require different movements than originally planned. ow-
ever since the teeth would be usually well aligned after the
presurgical phase any inaccuracies between the planned
and the obtained occlusion can be managed with intermax-
illary elastics.
n the other hand the predictability of the planned nal
occlusal outcome for the fabrication of the postsurgical
aligners could be more difcult in patients where the max-
illa will require segmentation in two or more pieces. n
these situations it is still possible that the presurgical dental
models could be segmented to the planned outcome and a
scan of this model could be used for the fabrication of the
surgical splint and the postsurgical aligners. owever it is
better recommended to take the scan or impressions after
the surgery to ensure a more precise t of the aligners es-
pecially if the segmentation is more that two pieces.
nother important consideration when segmenting the
maxilla is that the patient typically will have to maintain
the splint after surgery for  to  weeks prior to resuming
orthodontic movements.  splint covering the incisal and
occlusal surfaces of the teeth is bulky and cumbersome for
a patient in recovery after surgery.  splint not covering the
occlusal surfaces is typically recommended for the postsur-
gical phase prior to resuming the new aligners Fig. ..
n example of management of a patient with nvisalign
appliances into and out of the surgical procedure is illus-
trated in Figs. . . and .. This patient received a
eForte  osteotomy with a three-piece segmentation for
transverse expansion and vertical impaction of the poste-
rior segments see Fig. .. The occlusion  weeks after
surgery at the splint removal visit shows a slight discrep-
ancy between the surgical plan and the achieved outcome
see Fig. .. The patient was scanned  weeks later when
she was able to achieve enough range of motion. The align-
ers were delivered in conjunction with vertical elastics from
the miniscrews used during surgery. The occlusion was
nicely established to the projected outcome approximately 
months after surgery see Fig. ..
 surgical intermaxillary splint has been designed by 
ystems ockville   which consists of -printed
thin hard acrylic templates of the maxillary and mandibu-
lar arches attached together registering the nal occlusion
after the osteotomies. There is no need for wires or minis-
crews to tie the osteotomied dentition to the splint. The
teeth t into the splint by snapping physically into place. y
using this splint a transition to the postsurgical aligners
may be more easily achieved. This clear aligner orthodontic
splint was recently reported by aminiti and ou who
also described a reduced cost version produced by splinting
ssix-type trays through clear denture repair acrylic. ne
major disadvantage of this new type of intermaxillary
splint is that the miniscrews are typically not placed there-
fore intermaxillary elastics to maintain the occlusal result
after surgery require either hooks on the clear aligners or
cutouts for bonding buttons or brackets to the labial sur-
faces of some teeth.
Srery irt and CAT
 very novel approach to the application of the nvisalign
system in orthognathic surgery is its integration to the
238 Principles and Biomechanics of Aligner Treatment

Fig. 17.2 Surgical nal splint without occlusal coverage to be left for  to  wees postsurgically due to a three
piecemailla osteotomy.

Fig. 17.3 Threedimensional virtual surgical plan. A Presurgery.

 17 • Surgery First with Aligner Therapy 239

Fig. 17.3, cont’d B Planned osteotomies consisting of threepiecemailla with impaction of the posterior
segments and mandibular advancement with genioplasty.

Fig. 17.4 Postsurgical occlusion deviating slightly from the planned

occlusion. A ight buccal B eft buccal  frontal occlusal views.
240 Principles and Biomechanics of Aligner Treatment
surgery rst approach F. erhaps this is one of the most
attractive options for patients with dentofacial deformity
where the facial and smile esthetics drive their chief com-
plaint. urgery rst addresses the dentofacial deformity
from the beginning of treatment without any presurgical
orthodontics. y performing orthognathic surgery in this
manner it has been shown that patient satisfaction is
higher than with the conventional approach. This is un-
derstandable since obviating the presurgical phase the
typical decompensations that accentuate the dentofacial
deformity are eliminated. Furthermore the chief complaint
of the patient is immediately addressed without being post-
poned for a year or more as is the case with the conven-
tional approach.
nother condition where the combination of F and
T is largely indicated is in the treatment of patients with
obstructive sleep apnea who will undergo maxillomandibu-
lar advancement surgery. First the surgery addresses im-
mediately the medical functional condition without a de-
layed presurgical orthodontic phase secondly these
patients can achieve a good occlusion after surgery with the
use of clear appliances which are more acceptable to this
population particularly composed of adult patients.
n the FT nvisalign approach two common
treatment modalities have been applied. The rst consists of
placing labial orthodontic appliances including a wire
prior to surgery – weeks before. These xed appliances
are used for  to  months after surgery during which time
major intraarch movements are accomplished and inter-
maxillary vertical elastics are used to seat the occlusion.
This approach also has the advantage for the surgeon of
being able to tie the surgical splint to the orthodontic appli-
ances during maxillary and mandibular osseous xation.
Fig. 17.5 cclusion seated with intermaillary elastics and clear
aligners to the planned outcome after  months. A ight buccal
B eft buccal  frontal occlusal views.
The appliances are then removed after this short phase of
orthodontic xed therapy and nvisalign trays are given to
the patient until treatment completion. The second treat-
ment modality uses nvisalign as the only appliance for
orthodontic movement after surgery without the use of any
xed labial appliances. This approach unfortunately poses
the same challenge on maxillary and mandibular xation
for patients who do not have labial orthodontic appliances
during surgery. onetheless different alternatives have
been designed to facilitate and increase the predictability of
the xation with nvisalign appliances as described earlier.
 patient who underwent F in conjunction with nvis-
align is presented to illustrate this specic approach. This
case report also illustrates how the  virtual plan for the
surgical treatment can be integrated to the orthodontic 
dental plan represented in the linheck lign Technolo-
gies an ose  .
Cae Stdy
 -year-old female patient presented to the oral maxillo-
facial surgeon with the goal of improving her facial esthet-
ics Fig. .. he had received orthodontic treatment
during her adolescence consisting of camouage treatment
for a class  skeletal relationship addressed through the
extraction of maxillary rst premolars. The patient had
close to adequate arch alignment and a class  occlusion
with a -mm overjet Fig. . however there was a sig-
nicant facial convexity related to a large mandibular de-
ciency. The denture base was anteriorly positioned to the
apical base in the mandible and the lower incisors were
signicantly labially inclined. The patient also had steep
 17 • Surgery First with Aligner Therapy 241

A B C

D E
Fig. 17.6 Pretreatment etraoral photos. A Frontal lips relaed B smile  prole  bliue  bliue smiling
views. (A-C from Chang J, Steinaher D, Nanda R, et a “Srger-rt” aroah ith Iniaign thera to orret a a
II maoion and eere mandiar retrognathim J Clin Orthod. –

Fig. 17.7 Pretreatment intraoral photos. A ight buccal  B Frontal

Continued
242 Principles and Biomechanics of Aligner Treatment

Fig. 17.7, cont’d  eft buccal occlusion.  aillary and  andi

bular occlusal views. (From Chang J, Steinaher D, Nanda R, et a
“Srger-rt” aroah ith Iniaign thera to orret a a II mao-
ion and eere mandiar retrognathim J Clin Orthod. 
–

lower mandibular and occlusal planes. The maxillary posi-

tion of the incisors was overall adequate in the vertical and
anteroposterior dimensions and included a good inclina-
tion in reference to the cranial base Fig. .. ll third
molars had been extracted and the roots had adequate root
parallelism Fig. ..
To maximie the mandibular projection two options
were available. The rst one required the extraction of two
mandibular premolars to retract the mandibular incisors

Fig. 17.8 Pretreatment digitied lateral cephalogram. (From Chang J, Fig. 17.9 Pretreatment panoramic radiograph. (From Chang J, Stein-
Steinaher D, Nanda R, et a “Srger-rt” aroah ith Iniaign aher D, Nanda R, et a “Srger-rt” aroah ith Iniaign thera
thera to orret a a II maoion and eere mandiar retrogna- to orret a a II maoion and eere mandiar retrognathim
thim J Clin Orthod - J Clin Orthod -

achieving a large overjet to obtain a signicant mandibular
advancement with surgery. The second option was a nonex-
traction approach with a counterclockwise rotation of the
maxillomandibular complex in conjunction with a genio-
plasty. The patient opted for the second option as she did not
want any more tooth extractions and did not want a pro-
longed presurgical orthodontic phase of space closure. d-
ditionally with a nonextraction approach surgery rst was
indicated as it addressed her chief complaint of optimiing
her facial esthetics.
 virtual  plan was made for the surgical movements
Fig. .. hen her stone models were occluded in the
planned occlusion after surgery no transverse problems were
observed therefore no maxillary segmentation was planned
Fig. .. Figures . and  shows the specic move-
ments that were planned for this patient. The counterclock-
wise rotation of the maxillomandibular complex in conjunc-
tion with the genioplasty gave her approximately  mm of
projection at menton.
rior to surgery  impressions were taken for fabrica-
tion of the aligners that would address the mild crowding
and would also serve to detail the occlusion in the postsur-
gical phase.
The patient was advanced into an edge-to-edge incisor
overcorrection relationship. Four miniscrews on each
Fig. 17.10 A Threedimensional  virtual surgical plan presurgery.
17 • Surgery First with Aligner Therapy 243
quadrant were placed interradicularily to be used during
surgery for intermaxillary xation. Two weeks after sur-
gery facial esthetics were greatly improved with the surgi-
cal procedure Fig. .. t the occlusal level a slight
lateral open bite was noticed on the right side which was
expected based on the planned postsurgical occlusion Fig.
.. The patient was wearing intermaxillary elastics in
a class  direction from the more anterior miniscrews in the
maxilla to the most posterior miniscrews in the mandible.
Two months after surgery the facial swelling had reduced
signicantly Fig. . and the patient had almost 
of mandibular range of motion. ll the attachments from
the nvisalign appliance were bonded and small tubes
bonded to the mandibular rst molars. The patient started
the rst phase of aligners changing them on a weekly basis.
ntermaxillary elastics from the right maxillary miniscrew
implants were used to erupt the mandibular teeth on this
opposing quadrant into occlusion Fig. .. Five months
after surgery the lateral open bite on the right buccal seg-
ment was still evident Fig. ..  cantilever arm was
extended from the lower right rst molar to engage an elas-
tic extending from the maxillary right posterior miniscrew
Fig. .. The objective of this cantilever arm was to
provide an uprighting moment to the right lower molar
which was mesially tipped. ntermaxillary elastics were also
Continued
244 Principles and Biomechanics of Aligner Treatment

i 171 nt’d B andmar changes with the planned surgery in .  ounterclocwise rotation of the
maillomandibular comple. (A from Chang J, Steinaher D, Nanda R, et a “Srger-rt” aroah ith Iniaign
thera to orret a a II maoion and eere mandiar retrognathim J Clin Orthod. -

worn from two mandibular buttons on the premolars to a
hook in the maxillary aligner. istal to the mandibular
right canine the aligner was cut to allow for extrusion on
the mandibular buccal segment.
Twelve months after surgery the swelling had completely
resolved Fig. .. The occlusion was almost ideal at this
point with some minor renement required Fig. ..
fter another aligner renement phase the orthodontic
treatment was nished to a good occlusal and facial result
Figs. . and .. The lateral cephalogram depicts
the sagittal soft and hard tissue changes Fig. . while
the panoramic radiograph shows adequate root parallel-
ism Fig. .. The superimposition reveals the
remarkable soft and hard tissue mandibular advancement
Fig. ..
s part of her enhancing the patient’s facial esthetics a
rhinoplasty was performed approximately  months after or-
thognathic surgery.  very nice esthetic and occlusal outcome
was achieved in this patient with the FT approach.
nterestingly this patient was attending college in a loca-
tion that was at a far distance from our institution. ost of
her visits were carried during the summer when she was off
school. uring the academic year she was provided with
the aligners and her progress was monitored through pho-
tos she provided to our ofce every  months. The patient
had approximately  orthodontic visits.
 17 • Surgery First with Aligner Therapy 245

Fig. 17.11 Planned postsurgical occlusion with overcorrection. A ight

buccal B Frontal  eft Buccal views of the planned occlusion

Fig. 17.12 traoral photos  wees postsurgery. A Frontal B Prole and  Smiling views.
246 Principles and Biomechanics of Aligner Treatment

Fig. 17.13 Intraoral photos  wees postsurgery. A ight buccal

B Frontal and  eft buccal views of patient in occlusion.

Fig. 17.14 eduction of facial swelling  months postsurgery. A Frontal B Prole and  Smiling views. (From
Chang J, Steinaher D, Nanda R, et a “Srger-rt” aroah ith Iniaign thera to orret a a II maoion
and eere mandiar retrognathim J Clin Orthod. -
 17 • Surgery First with Aligner Therapy 247

Fig. 17.15 Intraoral photos  months postsurgery. A ight buccal

B Frontal and  eft buccal views. (From Chang J, Steinaher D,
Nanda R, et a “Srger-rt” aroah ith Iniaign thera to orret a
a II maoion and eere mandiar retrognathim J Clin Orthod.
-

Fig. 17.16 ateral open bite on the right is still present  months after
surgery. A ight buccal B Frontal and  eft buccal views of patient
in occlusion.
248 Principles and Biomechanics of Aligner Treatment

Fig. 17.17 antilever arm etended from bonded lower right molar tube to upright this tooth using an elastic from
the maillary miniscrews aligner cut distal to the lower right canine to allow eruption of the buccal segment.

Fig. 17.18 traoral photos  months postsurgery.

Fig. 17.19 Intraoral photos  months postsurgery. A ight buccal

B Frontal and  eft buccal views of patient in occlusion.
 17 • Surgery First with Aligner Therapy 249

Fig. 17.20 Posttreatment etraoral photos. A Frontal B Smiling and  Prole views. (From Chang J, Steinaher D,
Nanda R, et a “Srger-rt” aroah ith Iniaign thera to orret a a II maoion and eere
mandiar retrognathim J Clin Orthod. -

Fig. 17.21 Posttreatment intraoral photos. A ight buccal B Frontal and  eft buccal views of patient in occlusion.
Continued
250 Principles and Biomechanics of Aligner Treatment

Fig. 17.21, cont’d  aillary and  andibular occlusal views. (From Chang J, Steinaher D, Nanda R, et a “Srger-rt” aroah ith
Iniaign thera to orret a a II maoion and eere mandiar retrognathim J Clin Orthod. -

Fig. 17.23 Posttreatment panoramic radiograph. (From Chang J, Stein-

aher D, Nanda R, et a “Srger-rt” aroah ith Iniaign thera
to orret a a II maoion and eere mandiar retrognathim
J Clin Orthod. -

Fig. 17.22 Posttreatment lateral cephalogram. (From Chang J, Stein-

aher D, Nanda R, et a “Srger-rt” aroah ith Iniaign thera
to orret a a II maoion and eere mandiar retrognathim
J Clin Orthod. -

Fig. 17.24 Superimposition of the seletal and soft tissue changes. (From Chang J, Steinaher D, Nanda R, et a
“Srger-rt” aroah ith Iniaign thera to orret a a II maoion and eere mandiar retrognathim
J Clin Orthod. -

Cnlin
FT is a very appealing approach for adult patients
undergoing orthognathic surgery.   plan for the skeletal
movements in conjunction with a  plan for the dental
movements can be interconnected to achieve excellent oc-
clusal and esthetic results. Furthermore the presurgical
orthodontic phase can be obviated with the immediate
resolution of the dentofacial deformity. This approach may
become mainstream in the future as renements in the
techniques and improvements in the nvisalign appliance
are developed to increase predictability.
References
. owling  speland  rogstad  et al. uration of orthodontic
. aminiti  ou T. lear aligner orthognathic splints. J Oral
treatment involving orthognathic surgery. Int J Adult Orthodon
Orthognath Surg. -.
. elo  asparini  aragiola  et al. urgery-rst orthognathic
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orthognathic surgery how long does it take and why
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. omack  ay . urgical-orthodontic treatment using the
nvisalign system. J Clin Orthod. -.
. arcui  alassini  rocopio  et al. urgical-nvisalign
treatment of a patient with class  malocclusion and multiple
missing teeth. J Clin Orthod. -.
. agani  ignorino F oli  et al. The use of nvisalign system in
the management of the orthodontic treatment before and after class
 surgical approach. Case Rep Dent. .
. Taub  alermo . rthognathic surgery for the nvisalign patient.
Semin Orthod. -.
. ong  ee  unwoo  et al. ingual orthodontics combined
with orthognathic surgery in a skeletal class  patient. J Clin Orthod.
-.
. aik  oo  im  et al. se of miniscrews for intermaxillary
xation of lingual-orthodontic surgical patients. J Clin Orthod.
- qui .
Maxillofac Surg. .
approach vs traditional orthognathic approach oral health-related
quality of life assessed with  questionnaires. Am J Orthod Dentofacial
Orthop. -.
 18 Pain During Orthodontic
Treatment: Biologic
Mechanisms and Clinical
Management
TIANTONG LOU, JOHNNY TRAN, ALI TASSI, and IACOPO CIOFFI
The Importance of Orthodontic
Pain
Pain, as dened by the International Association for the
Study of Pain, is “an unpleasant and emotional experience
associated with actual or potential tissue damage or de-
scribed in terms of such damage.” he maority of patients
will experience arying intensities and freuencies of pain
during their course of orthodontic treatment. Pain is a
highly complex experience and is freuently an area of
concern among patients undergoing orthodontic treat-
ment. - he experience of pain is modulated by seeral
factors, such as the magnitude of noxious stimuli, emo-
tions, cognition, past experience and memories of pain, and
other concomitant sensory experiences.
rthodontic pain i.e., dental pain associated with orth-
odontic tooth moement can negatiely impact patient
compliance and oral hygiene,- lead to increased fre-
uency of missed appointments, and compromise the
oerall treatment result.  ear of pain is a maor reason
for patients to forego orthodontic treatment.   In one
particular surey, patients rated pain as the highest area
of dislie in regard to orthodontic treatment and raned
pain fourth among maor fears and apprehensions. ot
surprisingly, patients who experience reduced leels of
orthodontic pain tend to hae an improed leel of coop-
eration in treatment.   herefore, practitioners should
aim to reduce the pain experience to improe patient com-
pliance, decrease treatment times, and increase oerall
patient satisfaction.
er the last few decades, there has been an increased de-
mand from prospectie orthodontic patients for more es-
thetic alternaties to traditional metal bracets and wires. 
rthodontic appliances that are less isible may lead to im-
proed patient acceptance and improed uality of life.-
ore recent adancements in the specialty hae led to the
use of computer-aided design and computer-aided manufac-
turing AA technology to fabricate orthodontic
appliances. his has allowed clear aligner therapy A to
become aailable to the mass maret and emerge as a desir-
able treatment option for orthodontic patients. Since its
initial introduction in , A has rapidly increased in
popularity, and many orthodontists are utiliing clear align-
ers instead of conentional multibracet appliances to treat
patients with a wide ariety of malocclusions.
252
his chapter aims to proide an oeriew regarding
orthodontic pain, its relation to clear aligner therapy, as
well as the pharmacologic and nonpharmacologic clinical
management of pain experienced during orthodontic
treatment.
Biologic Mechanisms of
Orthodontic Pain and Clinical
Correlates
he underlying mechanism of pain during orthodontic
tooth moement is a result of the complex interplay be-
tween ast numbers of neurons and chemical mediators in
both the central and peripheral nerous systems. It is well
nown that orthodontic pain is primarily due to an inam-
matory reaction in the periodontium, which accompanies
orthodontic tooth moement. he application of orth-
odontic force results in a localied region induces ischemia,
inammation, and edema in the periodontal ligament
space and actiates a cascade of proinammatory media-
tors. ne of these mediators is the enyme cyclooxygen-
ase- -, a critical component in the synthesis of
prostaglandin, which is targeted by nonsteroidal antiin-
ammatory drugs SAIs. ociceptie stimuli exerted by
orthodontic appliances are primarily detected by sensory
bers such as  bers unmyelinated and thinly myelin-
ated Ad bers in the pulp and periodontal ligament. ther
substances that either actiate or sensitie nociceptors dur-
ing inammation include tumor necrosis factor-a -a,
interleuin  I-, I-b, bradyinin, enephalin, sero-
tonin, dopamine, glutamate g-amino butyric acid, and his-
tamine.- Studies hae demonstrated that eleated leels
of these compounds are associated with hyperalgesia.,
In addition, the actiated proinammatory mediators can
stimulate the release of neuropeptides from the afferent
nere endings into the surrounding tissues. Substance P
and calcitonin gene-related peptide P are two potent
neuropeptides that cause neurogenic inammation.-
hese sensory neuropeptides enhance inflammation
through interactions with epithelial cells to induce asodi-
lation and increase blood essel permeability., hey also
lead to mast cell degranulation and further release of pro-
inammation mediators such as histamine and serotonin.
hese inammatory mediators trigger the release of more
 18 • Pain During Orthodontic Treatment: Biologic Mechanisms and Clinical Management
neuropeptides, contributing to a continuation and intensi-
cation of the inammatory process. Substance P also
increases the leels of arious cytoines, such as - a,
I-b, and I-.  P stimulates the release of I-,
I-, and -a  hese cytoines sere as signaling mes-
sengers between immune cells and are important in bone
resorption, deposition, and remodeling. I-b is released
by broblasts of the gingia surrounding the teeth during
orthodontic tooth moement and is inoled in bone re-
modeling.  I- is a regulator of the immune response
during inammation and the formation and actiity of
osteoclasts.- -a is synthesied and released by
monocytes and macrophages and may be related to bone
remodeling.
he afferent bers hae their cell bodies residing in the
trigeminal ganglion of ecel cae and transmit electrical
signals to the central nerous system. hey ascend the
trigeminal spinal tract and enter the trigeminal sensory
nuclear complex. rom the trigeminal brainstem complex,
the nociceptie signal is transmitted to the thalamus and
eentually to the cerebral primary somatosensory cortex,
where the location of the signal is discriminated. op-down
neural pathways modulate the nociceptie stimuli coming
from the periphery. Although seeral brain areas are in-
oled in pain processing, still little is nown about how
pain is encoded in the brain. oweer, it is clear that the
pain and salience brain networs oerlap.
he initial pattern of pain experienced by patients under-
going traditional multibracet orthodontic appliance ther-
apy has been long studied and well documented.  -
Pain appears approximately  to  hours after orthodontic
forces are applied to the teeth, with pea leels freuently
occurring within the rst  hours after archwire place-
ment, followed by a steady decrease toward baseline leels
within  days ig. .. - hese ndings hae been
conrmed in seeral racial and ethnic groups - and
through the use of ecologic momentary assessment.
here also appears to be a diurnal ariation in pain experi-
enced by patients, with higher leels occurring in the
eenings and nights.
erall, patients are generally able to tolerate and adapt
to new appliances within  wee after placement. ow-
eer, female patients in middle adolescence hae been
reported to experience more pain than age-matched males
and younger patients when exposed to orthodontic proce-
dures. In addition, orthodontic pain is signicantly af-
fected by menstrual phase, with the pain leels being higher
Pain
24h 48h 72h 7 days
Fig. 18.1 Trajectory of dental pain after orthodontic procedures.
253
in the luteal phase. hile there is conicting reports on
the effect of age on orthodontic pain perception, there is
substantial eidence that the type of malocclusion and the
amount of crowding hae little effect on pain experienced
during orthodontic treatment.  hese ndings suggest
that pain is liely most affected by other factors, including
hormonal and psychological ariables. ne such example
is anxiety, which among other things can be dependent
on the relationship with the orthodontic care proider.
Orthodontic Tooth Pain in Clear
Aligner Therapy
rthodontic pain associated with A has been inesti-
gated in a limited number of studies. A appears to follow
a similar pattern of pain progression in terms of peaing
at  hours and trending toward baseline leels after
 days.,-, oweer, to date, A has mainly been
associated with more intermittent forces as compared
to conentional treatment with multibracet appliances,
although seeral companies are focusing on deeloping
materials that may proide more gentle and continuous
forces. nly a limited number of studies exist that examine
orthodontic pain in patients undergoing A with Inis-
align’s latest generation multilayered polyurethane-based
polymer, Smartrac. hese studies show a maximum
patient-reported pain score of  mm on a -mm isual
analogue scale AS, which may be considered mild and
of limited clinical signicance.  In preious literature,
xceed- thermoplastic material was used in the older
generation, and coincidently these studies showed signi-
cantly higher reported pain scores in the rst wee of
treatment up to  mm on AS.   imited eidence
suggests Smartrac may be more comfortable than older
generation materials, but further studies are needed to
alidate this.
Interestingly, with continued actie tooth moements of
the subseuent aligner stages, there is less pain reported by
patients compared to the rst stage aligners een if the rst
stage aligners are programmed to be passie without actie
tooth moements. his perhaps could be a result of the
accuracy, t, and deformation of the rst trays, the intro-
duction of iatrogenic posterior occlusal interferences, 
or the apprehension and stress inoled with starting orth-
odontic treatment with a new appliance.  Indeed, pain
perception with A, especially during the rst stage, is
signicantly related to an indiidual’s psychological stress
and anxiety.
In general, when compared to traditional multibracet
appliances, A results in less reported pain and improed
patient experience. iller et al. conducted the rst study
ealuating the differences in pain and impact on uality of
life experienced by patients undergoing A ersus multi-
bracet appliance therapy. his was a prospectie longitudi-
nal cohort study with  A patients and  multibracet
appliance patients. he participants were ased to use a
daily diary for  days, measuring functional, psychosocial,
and pain-related impacts. he diary consisted of ues-
tions adapted from the eriatric ral ealth Assessment
Index, a -point iert scale for demographic data, and a
isual analog scale for pain. he results showed that the
254 Principles and Biomechanics of Aligner Treatment
progression of pain in aligner treatment followed a similar
pattern to multibracet appliances, in which pain peaed
after  hours and gradually returned to normal. Addition-
ally, although the initial leels of pain were higher for the
multibracet appliance group, along with higher leels of
analgesic consumption, both groups recoered to baseline
within  days.
In a subseuent study by Shalish et al.,  patients
being treated by either buccal multibracet appliances, lin-
gual multibracet appliances, or A were recruited
to complete a health-related uality of life uestionna
ire  - and a -point scale for dysfunction during the
rst wee and on day . heir results showed the aerage
initial pain leels were consistently higher in the lingual
multibracet appliance and clear aligner groups, with anal-
gesic consumption paralleling the dynamics of the pain
leels although the difference did not reach statistical sig-
nicance. In all groups, the pain leels subsided within 
wee. hese results contradict the ndings by iller et al.,
which the authors attributed to a greater mechanical force
being applied in the aligner group compared to the buccal
multibracet appliance group.
o further elucidate and compare pain leels between
these orthodontic treatment modalities, uiyama et al.
conducted a prospectie clinical trial with  patients re-
ceiing either A, multibracet appliance therapy, or a
hybrid treatment combining both modalities. sing AS,
the participants were ased to record their pain leels at
time points of  seconds,  hours,  hours, and  to
 days post appliance insertion. his was repeated at wees
 and  after appliance deliery. heir results illustrated a
similar pattern of pain progression during the rst wee of
appliance deliery for all groups studied. oweer, the oer-
all pain leels were signicantly more intense and longer
lasting for the multibracet appliance group than either the
aligner or the hybrid group.
In a recent study by hite et al., patients were ran-
domly allocated to either clear aligner or multibracet ap-
pliance treatment groups to inestigate differences in their
pain leels. he participants were ased to complete a daily
diary with pain measured on AS. he diary was completed
at initial appliance deliery, daily for the rst wee, as well
as the rst  days after their next two follow-up appoint-
ments. he pattern of pain progression during the rst
wee following initial appliance actiation was in general
agreement with preious studies.,,,,, he clear
aligner group experienced consistently lower discomfort
than the multibracet appliance group during most of the
rst wee, with statistically signicant differences obsered
after  to  days. oreoer, analgesic consumption was
more freuent in the multibracet appliance group, and
their rate of consumption closely mirrored the pattern of
pain progression during the rst wee. Similarly, oer a
relatiely longer term of  months, the leel of pain was
less in the aligner group than the multibracet appliance
group. he patients in the multibracet appliance group
may hae experienced an increased initial inammatory
response, which led to increased sensitiation of the noci-
ceptors and higher pain sensation in subseuent follow-up
appointments.
he results of hite et al., uiyama et al., and iller
et al. comparing pain and discomfort between A and
multibracet appliances are in general agreement with one
another, as well as with past studies that demonstrated
multibracet appliances may cause more pain than remo-
able appliances.,,, As mentioned earlier, these results
were in contrast to the ndings from Shalish et al., who
reported the pain was greater in patients treated with align-
ers than multibracet appliances. ne possible explanation
for this discrepancy could be the ariations in the initial
archwires used between the studies. or example, the
classic nicel titanium ii or nitinol wires used in the
Shalish et al. study hae been shown to display higher pea
discomfort than the superelastic copper ii wires used in
hite et al., urthermore, the hite et al. study was the
only one to utilie Smartrac, a new aligner material
brought to maret by Align echnology in ,,
whereas the preious studies used the older xceed-
aligner material. imited eidence suggests Smartrac
may be more comfortable than preious materials,
although further studies are needed to erify this. astly,
Shalish et al. speculated that the differences in pain leels
obsered may possibly hae been due to a higher leel of
mechanical force being applied early in treatment for the
aligner group.
In summary, although orthodontic pain exists with A,
the current eidence seems to suggest it is of a lesser degree
than multibracet appliances, especially during the rst
wee. oweer, additional studies proiding more substan-
tial data are needed. As would be expected, actiation in the
aligner tray has been reported as the most freuent cause of
pain and discomfort. oweer, other issues leading to
pain in association with clear aligners might include nons-
mooth edges, tray, and attachment deformation.
Modulators of Pain: Psychological
actors
linical and pain assessment literature continues to be fo-
cussed on identifying and managing specic cognitie and
psychological factors that are related to the indiidual’s
experience of pain. In orthodontics, pain is a common se-
uela and expected with treatment. oweer, it is apparent
clinically that the perception of pain aries considerably
across indiiduals when the same stimulus, such as an
initial light archwire, is actiated. he expected pain from
an orthodontic adustment is generally belieed to be rela-
tiely minor and self-limiting howeer, some patients will
report a much different experience. It is generally ac-
cepted that particular affectie and cognitie behaioral
factors contribute to these differences in indiidual pain
perception. Specically releant to medical and dental
settings, pain perception is inuenced by factors such
as somatosensory amplication, anxiety, depression, and
catastrophiing.-
It has been shown that patients with prolonged pain
during orthodontic treatment exhibit higher leels of
anxiety than indiiduals with pain of short duration.
urthermore, experimentally induced orthodontic pain
ia elastomeric separators is greater in indiiduals who
exhibit higher leels of trait anxiety and somatosensory
amplication—a tendency to perceie normal somatic and
isceral sensations as being relatiely intense, noxious, and
 18 • Pain During Orthodontic Treatment: Biologic Mechanisms and Clinical Management
disturbing—as compared to indiiduals with low leels
of both. f importance, anxiety and other mood disor-
ders hae been found to be related to increased freuencies
of waing-state oral parafunctional behaiors, such as
waetime tooth clenching,- which are also associated
with temporomandibular disorders.,, herefore, it
might be uestioned whether anxiety, orthodontic pain,
and aw motor behaior are intertwined.
ecently, we performed a large web surey and re-
cruited  indiiduals subdiided into groups with high,
intermediate, and low leels of trait anxiety., lasto-
meric separators were applied to the molars and pain and
freuency of tooth clenching episodes were recorded for
 days. A signicant correlation orthodontic pain and fre-
uency of tooth clenching was obsered. In participants
with high anxiety, the decrease in orthodontic pain was
paralleled by a decrease in the freuency of waetime
tooth clenching episodes. hese results suggest that indi-
iduals with high trait anxiety may respond with an
aoidance behaior decrease of aw motor actiity to
orthodontic stimuli as a method to reducing their pain
experience. he relationship between aw motor actiity
and orthodontic pain is supported by a recent study that
demonstrated a reduced masticatory performance in orth-
odontic patients during the period in which they reported
the maximum leels of pain and creicular I-b. ow-
eer, there is some eidence of increased aw muscle acti-
ity with A,, leading to aw muscle tenderness of
limited clinical signicance.
ec et al. estimated the contribution of psychological
factors to orthodontic pain. f interest, for eery pain
catastrophiing scale PS magnication score of  unit
higher, the relatie ris of being a high-pain responder
was .. agnication refers to an indiidual’s ten-
dency to exaggerate the threat alue of nociceptie in-
puts. In this study, the authors showed that cold sensi-
tiity signicantly predicts the pain experienced, with
those reporting greater scores for cold sensitiity haing
greater orthodontic pain. his result supports the hypoth-
esis that somatosensory amplication plays a maor role
in orthodontic pain experience. aluation of the aboe-
mentioned psychological constructs in a clinical setting
utiliing alidated uestionnaires is adisable to identify
indiiduals who may be more sensitie to pain and dis-
comfort during orthodontic therapy. Anxiety and symp-
tom perception management might be recommended for
those susceptible indiiduals.
Clinical Considerations for the
Management of Orthodontic Pain
In the last decade, seeral reiews and clinical studies hae
been published on the management of orthodontic pain. It
is well nown that pharmacologic approaches with oer-
the-counter analgesics are effectie in managing orthodon-
tic pain. In particular, acetaminophen paracetamol is
usually prescribed in place of SAIs to aoid possible
effects on the rate of tooth moement., Indeed,
SAIs hae been reported to interfere with the synthesis
of prostaglandin  P, which is nown to be an im-
portant chemical mediator during the bone remodeling
255
process., A recent ochrane reiew, including 
randomied controlled trials s and , participants
aged  to  years, did not nd any eidence of a difference
in efcacy between SAIs and paracetamol at , , or
 hours postinterention. hey concluded that analgesics
are more effectie at reducing orthodontic pain than pla-
cebo or no treatment.
Sandhu and ecie examined the diurnal ariation
of pain in  orthodontic patients. onsistent with the
aboementioned studies, pain was reported to pea after
 hours. Interestingly, during the pea period, orthodontic
pain was lower during the afternoon as compared to the
night and morning. herefore, the authors suggested that
patients should be adised to tae analgesics accordingly
and need not be prescribed routine analgesics to be taen
eery  to  hours. In addition, they suggested that preemp-
tie administration of analgesics may be more effectie
than posttreatment administration, as the traditional ad-
ministration at regular interals does not consider tempo-
ral ariations in orthodontic pain. oweer, the preiously
mentioned reiew indicated there is ery low eidence
suggesting preemptie ibuprofen gies better pain relief at
 hours than ibuprofen taen posttreatment. inally, it
must be noted that the combination of acetaminophen plus
ibuprofen proides greater analgesic efcacy than acet-
aminophen or ibuprofen alone.
Special considerations should be made for patients with
a history of regularly taing pain medications. Indeed, a
recent literature reiew which included animal studies
suggested that long-term consumption of pain relieers can
signicantly affect the rate of orthodontic tooth moe-
ment. Surprisingly, they found that animals in treatment
with ibuprofen did not show a signicant decrease in orth-
odontic tooth moement, as some preious human studies
had shown. n the other hand, long-term administration
of indomethacin, etorolac, and high doses of etoricoxib
decreased the amount of tooth moement. oweer, cau-
tion should be taen when interpreting these results due to
the uestionable uality of eidence that is aailable.
Seeral nonpharmacologic approaches hae been con-
sidered to manage orthodontic pain. In another recent
ochrane reiew, leming et al. included  s with
 participants and analyed the effects of low-leel laser
therapy , ibratory aduncts, experimental chewing
aduncts e.g., bite wafers and chewing gum, and psycho-
social and physical interentions on orthodontic pain. hey
concluded that laser irradiation may help reduce orthodon-
tic pain in the short term. n the other hand, eidence to
support other methods is of low uality.
It is the opinion of the authors that nonpharmacologic
interentions should be used wheneer possible to reduce
orthodontic pain able ., proided they do not expose
patients to harm or additional costs during treatment they
should be used especially when a medical condition pre-
ents the use of recommended analgesics. f foremost im-
portance, clinicians should establish a relationship of trust
with patients and improe their communication sills to
reduce nocebo and faor placebo effects. erall, a proper
pain management approach would reuire a careful base-
line assessment of pain predictors, psychological factors,
and patient expectations. oreoer, placebo and nocebo
effects should be considered when communicating with
256 Principles and Biomechanics of Aligner Treatment

Tale 181 Strategies to educe Pain During Orthodontic . iannopoulou , udic A, iliaridis S. Pain discomfort and creicular
Treatment uid changes induced by orthodontic elastic separators in children.
J Pain. -.
Pharmacologic Acetaminophen or igh leel of eidence . iuchosi P, ields , ohnston , et al. Assessment of per-
iuprofen P to support pain ceied orthodontic appliance attractieness. Am J Orthod Dentofacial
reduction ith this Orthop. S-S.
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ability, and alue of orthodontic appliances. Am J Orthod Dentofacial
onpharmacologic n Cheing adjuncts o leel of eidence Orthop. , e-e, discussion -.
to support orthodon . Shalish , ooper-aa , Igi I, et al. Adult patients’ adustability
n oleel laser
tic pain reduction to orthodontic appliances. Part I a comparison between labial,
therapy
ith this treatment lingual, and Inisalign. Eur J Orthod. -.
n iratory stimulation . ’rien , ay , ox , et al. Assessing oral health outcomes for or-
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approach orthodontics. J Orthod. -.
. ong . Inisalign A to . Am J Orthod Dentofacial Orthop. 
PRN, Pro re nata (As necessary). -.
. orton , erahshan , aa S, et al. esign of the Inisalign system
performance. Semin Orthod. -.
. Par , ae , ee , et al. ypoxia inducible factor- alpha
patients. lasini et al. highlighted that negatie patient- directly induces the expression of receptor actiator of nuclear
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munication with patients should be well-balanced by not -.
. ee , atsuiaa , hashi S, et al. ypoxia actiates the
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side effects and limiting information regarding benets. -.
. yranides S, uang , aber . eurologic regulation and orth-
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Movement. asel arger -.
. oreall I, atsson , orsgren S. ain sensory neuropeptides,
but not IP and P, are inoled in bone remodeling during
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. Spielberg , orsuch , e . Manual of the StateTrait Aniety
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. how . Effects of Aniety and Daytime Clenching on Orthodontic Pain
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. ameiro , Schult , rein P, et al. Association among pain,
masticatory performance, and proinammatory cytoines in cre-
icular uid during orthodontic treatment. Am J Orthod Dentofacial
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. astroorio , argellini A, ucchese A, et al. ffects of clear
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. ou , ran , astroorio , assi A, iof I. aluation of mastica-
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e-e.
. Arias , arue-roco . Aspirin, acetaminophen, and
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. oche , isneros , Acs . he effect of acetaminophen on tooth
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. eier , anda S, urrier , et al. he effects of exogenous
prostaglandins on orthodontic tooth moement in rats. Am J Orthod
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. on A, arrison , orthington , et al. Pharmacological
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. Sandhu S, ecie . iurnal ariation in orthodontic pain clinical
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-.
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. arygiannais A, alamanos , Athanasiou A. oes long-
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. leming PS, Strydom , atsaros , et al. on-pharmacological
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. lasini , osas S, olloca . Placebo hypoalgesic effects in pain
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 19 Retention and Stability
Following Aligner Therapy
JOSEF KUČERA and IVO MAREK
Retention and Stability
in Orthodontic Treatment
INTRODUCTION
Orthodontic treatment is an area of medicine and dentistry
that has to address not just health and function but also
aesthetics. It is usually the aesthetic considerations that
make patients seek out orthodontic treatment in the rst
place. Achieving an excellent aesthetic and functional
result can be lengthy and expensive, therefore it is in the
interests of both the patient and the clinician that the result
of orthodontic treatment remains stable in the long term.
Unfortunately the importance of the retention phase is
often underestimated, hen in reality it is as important to
the patients as the active orthodontic treatment itself.
he period after the completion of active treatment can
be divided into a retention period and a postretention
period. he purpose of the retention phase folloing active
orthodontic treatment is to prevent relapse dened as the
natural tendency of the teeth to migrate into their original
position in the dental arch and to eliminate the inuence of
other factors that might destabilie the result. It is very dif
cult to say ho long the retention phase should last. he
literature offers many recommendations, although they
vary considerably and are often vague. ome authors sug
gest that, folloing orthodontic treatment, teeth should be
held in the position achieved by treatment for as long as it is
necessary to sustain the result, or that the retention phase
should be as long as needed and as short as possible.
Others suggest that retainers should be used until the
patient’s groth is complete or the third molars erupt, or
for a period of  years or even  years, or simply as long
as the patient ishes to keep the teeth aligned.
It is generally recommended that nongroing patients
ear retainers for at least  year and is biologically dened
as the completion of the reorganiation of bone and peri
odontal ligaments around the teeth. ollagen bers are
reorganied ithin the rst  to  months. his period is
critical, and the earing of retention appliances is essential
because relapse is very likely at this stage after this critical
period the risk decreases substantially. oever, the reor
ganiation of elastic supracrestal bers may take more than
 year, hich makes the retention of severely rotated teeth
particularly difcult some authors recommend adjunctive
surgical procedures such as berotomy to decrease the
amount of relapse., In groing patients retainers should
be orn until the groth is complete. At the time patients
stop earing the retention appliances, the postretention
period begins, and it is only then that e get a true picture
of the stability of the original result that had been achieved
by the orthodontic treatment. uring the postretention
period numerous factors and the complexity of their inter
actions may ultimately destabilie treatment results.
FACTORS INFLUENCING LONG-TERM STABILITY
ith regard to stability there are some general guidelines
and recommendations for orthodontic treatment, and so
long as these are respected hen making and carrying out
the treatment plan they tend to produce stable results ith
relatively little risk of relapse. In such cases, longterm
changes in dental arches of treated patients are then simi
lar to those occurring in untreated subjects.
efore starting treatment, orthodontists need to keep in
mind that the position of the teeth and the shape of the
dental arches are the balanced result of many factors, espe
cially the inuence of the forces exerted by the surrounding
soft tissues i.e., pressure from the cheeks, lips, and tongue
that create a “neutral one” or “one of stability.” Orthodon
tic movement of the teeth outside of this neutral one
pushes them into an unbalanced one, ith conseuent
relapse., he shape of the dental arch, particularly the
mandibular arch, should therefore be respected in the plan
ning and implementation of treatment because changes in
arch shape tend to relapse into the original shape in the long
term., he upper dental arch may be expanded more
than the loer arch in indicated cases rapid maxillary
expansion hoever, even in these cases, the longterm sta
bility appears to be uite problematic. Any changes in the
loer intercanine distance are also very prone to relapse,,
partly because decrease in the loer intercanine distance is
due to the natural changes that occur in the dental arch as
a result of aging., he uality of articulation and inter
cuspation can also be very important for the longterm sta
bility.,, he correct intercuspation of the teeth in lateral
segments ith high cusps itself provides the best retention,
both in sagittal and transverse dimensions. It is also impor
tant to achieve the correction in the vertical direction, and
especially for sufcient correction of the deep bite, as its
deepening reduces the space for the loer incisors. Incisor
shape can also be a source of posttreatment instability. In
triangularshaped incisors, recontouring of the approximal
surfaces i.e., interproximal enamel reduction, stripping
provides more stable contact beteen the incisors. Accord
ing to some studies, this stabiliing effect of loer incisor
stripping is comparable to the efciency of bonded retain
ers., imilarly, the adjustment of large proximal enamel
ridges on the palatal surfaces of the upper incisors is also
important for the stability of the incisor region.
259
260 Principles and Biomechanics of Aligner Treatment
ontinuing groth is a separate issue and needs to be
addressed ith particular attention in more pronounced
skeletal malocclusions, especially in the sagittal and vertical
dimensions, hich continue to gro over a longer period
than in the transverse dimension. Unfavorable groth of
the jas has a negative impact on the occlusal relationship
and on the position of incisors due to the dentoalveolar
compensation process. his is one of the reasons hy it is
recommended to plan comprehensive treatment of severe
skeletal malocclusions after the patient’s groth is com
plete. oever, even after groth completion, the dental
arches are also subject to changes related to the patient’s
aging, and these processes are in fact lifelong and may result
in the development of irregularities in the incisor seg
ment    that often bring patients back for retreatment.
Retention Protocols and the
Choice of Retention Appliance
RETENTION PROTOCOLS
o date, there is no universal retention protocol, and there
is insufcient highuality scientic literature to reliably
A B
C
Fig. 19.1 Examples of relapse after orthodontic treatment, where either the patient failed to wear the retention
appliances after rapid maxillary expansion (A-C) or the retention regime selected was insufcient for a noncompliant
patient the rotational relapse of lateral incisors
establish such a protocol in terms of the length of the reten
tion phase, the earing regime, and the choice of type of
retention device.  his is because e cannot generalie a
single procedure for patients ho differ in diagnosis, sever
ity of the malocclusion, age, type of groth, treatment
type, and uality of treatment result. hus the choice
of retention device should alays be individualied, ith
consideration of all the potential factors of instability men
tioned earlier. his approach is called “differential reten
tion,” meaning that for every patient, orthodontists must
focus and aim the retention on those points that pose the
greatest threat and risk of relapse in the individual patient
ig. ..
According to surveys on retention protocols, the most
common retention devices are the aley retainers and
clear thermoplastic retainers. or the mandible, a xed
retainer is often indicated, either on its on or in combina
tion ith a removable appliance.  An increasing trend
has been observed in the use of thermoplastic retainers,
hich patients prefer because of their good aesthetics and
inconspicuousness. A similar trend can also be observed
ith xed retainers in both jas. In terms of the freuency
of use of the various retention devices, an indenite use of
xed retainers is recommended by many clinicians.  
 19 • etention and taility ollowing Aligner Therapy 261

D G

E H

F I
Fig. 19.1, c’ (-) and palatal moement of upper left canine (-) shown could hae een preented y onding
a xed retainer and including prolematic teeth

If the decision is made to use a retention appliance long
term, a xed retainer seems to be the best option mainly
because it prevents relapse of the aesthetically important
anterior teeth very efciently and ithout any need for
patient cooperation., onded retainers have also been
described in the literature as safe, predictable, and posing
no health risks to the patient.,, ome studies, hoever,
have indicated that there is a tendency toard increased
buildup of plaue and calculus around bonded retainers
ig. ., having negative conseuences on the periodon
tium hoever, this can be minimied ith regular care,
exercised by the patient and a dental hygienist.
he biggest disadvantage of bonded retainers that
impacts their longterm or lifelong use is failure rate.
According to the literature, the failure rate varies idely,
from . to ., oever, e believe that the occur
rence of common failures, such as abrasion of the layer of
adhesive resin caused by food attrition or occlusal contacts,
is only a matter of time ig. .. Other considerable risks
associated ith prolonged use of bonded retainers are the
socalled unexpected complications, here unexpected
tooth movement occurs, even hen the integrity of the
bonded retainer has not been compromised in any ay. he
incidence of these complications is uite small, occurring
262 Principles and Biomechanics of Aligner Treatment

A B
Fig. 19.2 Calculus accumulation and gingial inammation around the lower onded retainer (A and B)

A B

C D
Fig. 19. Examples of failures of onded retainers (A) The detachment of a composite resin layer is usually a conse-
uence of onding errors (B) The loss of the adhesie layer due to mastication or premature contact on the onded
retainer (C) Premature contact on the retainer wire, wire fatigue, or selection of a wire with insufcient mechanical
properties (small diameter dead-soft wire) resulting in fracture of the wire () Extending the upper retainer to the
canines increases the ris of fracture, with conseuent wire actiation and unwanted tooth moement (Kučera J,
Littlewood SJ, Marek I. Fixed retention: pitfalls and complications. riti ental Journal   ( .

in approximately  to  of cases,, but their clinical
conseuences can be very severe. In addition, it is estimated
that up to  of such cases reuire retreatment. here
are to distinct types ig. ., characteried by a torue
difference beteen to adjacent incisors  effect or op
posite inclination of contralateral canines ist effect.,
hese complications are surprising because they may ap
pear after a relatively long period of problemfree retention,
often occurring after several years.,, he unanted
tooth movement can be so pronounced that the root is
moved outside of the alveolar bone ig. ., hich is
in many cases accompanied by the occurrence of gingival
 19 • etention and taility ollowing Aligner Therapy 26

A B

C D
Fig. 19. Two distinct types of unexpected complication of lower onded retainers opposite torue on two ada-
cent incisors ( effect A, B) and opposite inclination of contralateral canines (Twist effect C, ) Both  effect and
Twist effect may e accompanied y seere gingial recession (A, C) (,  ro Kucera J, Strelo J, Marek I, et al. reat
ent o colication aociated wit lower ed retainer. J Clin Orthod. .

B
Fig. 19.5 nexpected complication of lower
onded retainer (Twist effect) lower left ca-
nine moing out of the ony enelope (A-C)
ignicant ony dehiscence can e identied
on dental cone-eam computed tomogra-
phy (B, C) (Marek I, Kučera, J. Twist-effect, X-effect
C and other unexpected complications of xed re-
tainers – original article. LKS , (.
26 Principles and Biomechanics of Aligner Treatment

recession. In such severe cases, orthodontic retreatment is
necessary, and often a surgical periodontal intervention
may also be needed ig. .. 
ongterm or lifelong retention is not ithout risk. It
should be indicated ith caution, and it is essential that xed
retainers are regularly checked by an orthodontist or during
regular dental or hygiene checkups. It is also very important
that dentists and dental hygienists ho see the patients most
freuently are informed about the retention devices used and
their associated risks, no matter ho small. his is especially
important for the dental health care providers to help their
patients manage because many of the patients consider the
orthodontic treatment completed hen the xed appliance is
removed, and their regular attendance for checkups at the
orthodontic ofce in the retention phase can be a problem
ig. .. It is needless to say that early detection of these
complications can minimie the damage to adjacent tissues
and facilitate the subseuent care.

A B

C D

E F
Fig. 19.6 Treatment of a complication associated with a lower onded retainer (A-C) ower left central and lateral
incisors seerely proclined y a fractured onded retainer and lingual gingial recessions occurring on oth incisors
(-) etreatment with a full lower xed appliance corrected the torue of the incisors and was followed y a peri-
odontal reconstructie surgery
 19 • etention and taility ollowing Aligner Therapy 265

G H

I
Fig. 19.6, c’ (-) inal reconstruction with full porcelain crowns and onding of a new lower xed retainer

100%

90%

80%
Attendance of patients at recall

70%

60%

50%

40%

30%

20%

10%

0%
1 2 3 4 5 6 7 8 9 10 11 12
Years in retention
Fig. 19. hen long-term retention is indicated, regular recalls are necessary to chec retainers howeer, atten-
dance of patients decreases in the retention period, as seen on this graph (Fro Kucera J, Marek I. Uneected
colication aociated wit andiular ed retainer a retroectie tud. Am J Orthod Dentofacial Orthop
.
266 Principles and Biomechanics of Aligner Treatment
APPLIANCES FOR RETENTION AND
INDICATIONS OF ARIOUS RETENTION DEICES
ased on the biologic principles and knoledge of factors
that inuence the position of teeth in the retention phase,
several combinations of retention appliances have been
recommended. ost often a removable aley retainer
ith van der inden labial bo and Adams clasps on the
rst molars is used for both the upper and loer jas
ig. .. aley retainers are orn largely during the
nighttime only. he second option is clear thermoplastic
retainers, suitable for both night and daytime ear
ig. .. aley retainers are indicated especially for
patients ho have need for an increased stabiliation of the
canine positions. Other typical indications are patients after
transverse expansion or after treatment of a deep bite hen
the appliance is also serving as a bite plate. In class II cases
here intermaxillary elastics or a bitejumping device as
used, an activator ith van der inden labial bo and
Adams clasps on maxillary molars ig. . or to clear
thermoplastic appliances ith class II precision ings
should be considered. In the majority of patients, each of
these removable retainers is used in combination ith an
upper or loer bonded retainer. onded retainers are most
often made of thin multistrand exible steel archires of
various strengths and ith various cross sections most of
ten the cross section varies beteen . and .in.
he ire is shaped and passively attached by a o compos
ite resin to all anterior teeth in the loer ja canines and
incisors on the lingual surface, preferably in the apical third of
A B
C (B), and lateral (C) iews
teeth. Alternatively, thick monolament stainless steel, cobalt
chromium or titaniummolybdenum ires bonded only to the
canines can be used cross section ranges beteen . and
. in. In the upper arch, xed retainers most often are
limited only to the incisor segment, hile in some patients ith
increased need for canine stabiliation e.g., palatally or buc
cally impacted canines the canines are also included in the
bonded retainer ig. .. he use of xed retainers is par
ticularly necessary in patients ith compromised periodontal
health, here they also serve as periodontal splints, as ell as
in patients ith spacing or midline diastemas, after compli
cated space closure folloing extractions, severe tooth rota
tions, open bite, or ith impacted canines, or even as a space
maintainer before dental implants are placed ig. ..
SPECIFICS OF RETENTION FOLLOING CLEAR
ALIGNER TERAPY
eneral principles that apply in treatment planning and
that fundamentally inuence the occurrence of relapse and
the stability of treatment are eually relevant in the treat
ment by xed or clear aligner appliance treatment. o
ever, the retention phase folloing orthodontic treatment
using clear aligners is different to some extent from that
folloing use of xed appliances.
hen planning retention after clear aligner therapy
A, the greatest disadvantage is the complicated achieve
ment of nal articulation and intercuspation in the poste
rior segments, as opposed to xed appliance treatment,
here an ideal occlusal contact can be achieved in the nal
Fig. 19. awley retainer with frontal ite plane in occlusal (A), front
 19 • etention and taility ollowing Aligner Therapy 26

A B
Fig. 19.9 acuum-formed thermoplastic retainer in the upper aw in frontal iew (A) and smile (B)

A B

Fig. 19.10 etention actiator after class  treatment in lateral right

C (A), frontal (B), and lateral left (C) iews

stage of treatment by use of settling elastics. In A, a
posterior open bite often occurs. his may be a conseuence
of various factors, including premature anterior contact of
incisors ig. . due to insufcient intrusion of loer
incisors or incorrect torue of upper or even loer incisors.
In addition, the intrusive inuence of masticatory forces on
aligners in the posterior segments plays an important role.
his situation can be solved by additional aligners never
theless, even then a slight open bite often persists. In these
cases, posterior teeth need to be alloed to achieve their best
possible contact natural settling ith their antagonists. In
this regard, the use of clear aligners for retention may not be
appropriate, as it might hinder this natural process entirely,
thereby making the settling less effective than hen aley
appliances are used ig. ..
On the other hand, the abovementioned intrusion effect
of clear aligners on the posterior segments is advanta
geous hen treating openbite cases. ompared to the
26 Principles and Biomechanics of Aligner Treatment

A B

C D

E F
Fig. 19.11 ifferent types of commonly used xed retainers pper retainers can include incisors only (A), or een
oth canines, either continuous (B) or segmented (C) the segmented ersion is more suitale ecause premature
contact on the retainer can e aoided, therey decreasing oth the incidence of fracture and the adhesie layer
() ower xed retainer usually includes canines and incisors estiular retainers can e used after difcult extrac-
tion space closure (E) or as a space maintainer prior to implant placement ()

xed appliance treatment, clinically signicant intrusion
of molars and premolars can be achieved even ithout
using temporary anchorage devices. hese intrusion
movements also seem to be very stable, though valid data
to verify this premise are lacking currently ig. . In
openbite cases here incisor extrusion is a part of the
treatment, it is important that both upper and loer xed
retainers extending from canine to canine are used as part
of the retention protocol. Additionally, it is essential that
all teeth in the upper and loer arches are included
in thermoplastic retainers to prevent unanted eruption
of the last molars and conseuent reopening of the bite
ig. ..
he apparent advantage of A is the nal position of
the loer incisors can be predicted very precisely during
treatment planning, alloing the clinician to predict and
reduce unanted proclination of incisors and thus
expected relapse as ell ig. .. herefore functions
 19 • etention and taility ollowing Aligner Therapy 269

A B

C D

E F

G H
Fig. 19.12 Examples of typical indication in which use of xed retainers is recommended (A, B) ifcult extraction
space closure (C, ) arge midline diastema closure in a periodontally compromised patient (E, ) pace closure in
a patient with generalied spacing (, ) eere crowding and tooth rotations
20 Principles and Biomechanics of Aligner Treatment

A B

C D

E F
Fig. 19.1 (A, B) ateral open ite often occurs after aligner treatment (C, ) The clinical picture at the end of treatment
may thus differ when compared to the nal situation depicted in the treatment planning software (E, ) oweer, the
clinical situation after  years in recall shows that the teeth will eentually settle into the desired position

like grip and superimposition in treatment planning
softare should be included in the standard protocol hen
planning nonextraction therapy in cases of croding or
in class II cases here use of elastics is planned. espite
providing exact control of the loer incisor position, xed
retainers may still be recommended as the most reliable
retention method for stabiliing the position of the loer
incisors in the long term. After class II treatment, the use of
a retention activator in construction bite or thermoplastic
retainers ith precision ings should be considered to
maintain the interarch occlusal change. In crossbite cases
here transverse expansion as performed, it is more suit
able to use a removable retention plate because it is more
rigid and maintains the nal transverse dimension better
and can be easily adjusted by selective grinding here
settling is needed to nalie the articulation.
RETENTION PROTOCOL AND SCEDULE
OF CECUPS IN TE RETENTION PERIOD
In standard cases the folloing retention protocol is used in
our institution In the rare cases hen patients do not have a
bonded maxillary xed retainer, fulltime ear of the reten
tion appliance for the rst  months is recommended this
most often involves a thermoplastic retainer during the day
and a aley appliance overnight, achieving  hours of
retainer ear, ith the exception of time that the patient
spends eating, drinking, teeth brushing, and possibly partici
pating in sport activities after the month period, the
patients are then asked to ear retention appliances over
night for the rest of the rst year of retention, folloed by
every other night in the second year, tice a eek in the third
year, and once a eek afterards hen a xed retainer is
 19 • etention and taility ollowing Aligner Therapy 21

D
Fig. 19.1 atural settling of teeth after orthodontic treatment in recall after  months, as isualied on T scans of a
patient wearing a awley retainer at nighttime (A, B) and a thermoplastic retainer (C, )
22 Principles and Biomechanics of Aligner Treatment
A D
B E
C F
Fig. 19.15 Treatment of an open ite with aligners that was facilitated y intrusie force in the lateral segments
used, the protocol remains the same, except that the remov
able appliance is orn only at nighttime from the beginning.
xceptions to the general protocol include groing patients
ith sagittal or vertical malocclusions, ho should continue
to ear retention appliances until their groth is nished,
and patients ho have undergone orthognathic surgery
or those ith compromised treatment results, here an
increased tendency to relapse may be expected, ho are also
recommended a prolonged retention period.
atients are instructed to attend regular checkups
throughout the retention period. he recommended sched
ule is once every  or  months during the rst year, tice
a year in the second year, and at least once a year thereaf
ter. urrently there is a tendency to maintain the bonded
retainers indenitely and independently of the original
malocclusion but only after a prior agreement ith the
patient. atients are instructed that the retention may be
discontinued at some point but that their dentition is sub
ject to continuous change throughout their lives, and this
change may manifest itself in the occurrence of various
irregularities in the aesthetically exposed anterior segment.
hus patients must either accept the risk of these changes
or they must continue ith a bonded or removable retainer
if they ant to maintain their teeth alignment. oever,
ith due respect to the expected and unexpected complica
tions associated ith the prolonged use of a bonded
retainer, they need to be checked regularly, at least once
a year.
 19 • etention and taility ollowing Aligner Therapy 2

A D

B E

C F
Fig. 19.16 elapse of anterior open ite due to short retention thermoplastic retainers and conseuent extrusion of
second molars ituation after treatment (A-C) and  years in recall (-)

.5

.5

.2 .5

.3 .5
.5 .5

Fig. 19.1 Treatment planning software can e used to plan the position of lower incisors exactly, aoiding unwanted
proclination of the lower incisors and thus preenting the ris of relapse
2 Principles and Biomechanics of Aligner Treatment
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. slambolchi , oodside , ossou . A descriptive study of
mandibular incisor alignment in untreated subjects. Am J Orthod
Dentofacial Orthod. .
. ehrents . roth in the aging craniofacial skeleton. onograph
, raniofacial roth series. Ann arbour enter for uman
roth and evelopment University of ichigan . In anda
, anda . onsiderations of craniofacial groth in longterm
retention and stability is active retention needed Am J Orthod
Dentofacial Orthop. .
. ittleood . videncebased retention here are e no Semin
Orthod. .
. ittleood , illett , oubleday , et al. etention procedures for
stabilising tooth position after treatment ith orthodontic braces.
Cochrane Database Syst Rev. .
. ratt , luemper , artseld r , et al. valuation of
retention protocols among members of the American Association of
Orthodontists in the United tates. Am J Orthod Dentofacial Orthop.
.
. enkema A, ips , ronkhorst , et al. A survey on orthodontic
retention procedures in the etherlands. Eur J Orthod. 
.
. oland , ichens , illiams A, et al. he effectiveness of aley
and vacuumformed retainers a singlecenter randomied controlled
trial. Am J Orthod Dentofacial Orthop. .
. ai , rossen , enkema A, et al. Orthodontic retention
procedures in iterland. Swiss Dent J. .
. admos A, udalej , enkema A. pidemiologic study of
orthodontic retention procedures. Am J Orthod Dentofacial Orthop.
.
. Årtun , padafora A, hapiro A. A year folloup study of
various types of orthodontic caninetocanine retainers. Eur J
Orthod. .
. enkema A, enkema A, ronkhorst , et al. ongterm
effectiveness of caninetocanine bonded exible spiral ire lingual
retainers. Am J Orthod Dentofacial Orthop. .
. Årtun . aries and periodontal reactions associated ith longterm
use of different types of bonded lingual retainers. Am J Orthod.
.
. andis , lahopoulos , adianos , et al. ongterm periodontal
status of patients ith mandibular lingual xed retention. Eur J
Orthod. .
. ogers , Andres . ependable techniue for bonding a  x 
retainer. Am J Orthod Dentofacial Orthop. .
. törmann I, hmer U. A prospective randomied study of different
retainer types. J Orofac Orthop. .
. učera , arek I. Unexpected complications associated ith
mandibular xed retainers a retrospective study. Am J Orthod
Dentofacial Orthop. .
. atsaros , ivas , enkema A. Unexpected complications of
bonded mandibular lingual retainers. Am J Orthod Dentofacial Orthop.
.
. arek I, učera . isteffect, effect and other unexpected
complications of xed retainers. LS. .
. aera , udalej , atsaros . evere complication of a bonded
mandibular lingual retainer. Am J Orthod Dentofacial Orthop.
.
. učera , treblov , arek I, et al. reatment of complications
associated ith loer xed retainers. J Clin Orthod. 
.
. rátná , arek I, ycová . ettling after orthodontic therapy
according to type of retention. Ortodoncie. .
. annessy , arvey , AlAadhi A. A randomied clinical trial
comparing mandibular incisor proclination produced by xed labial
appliances and clear aligners. Angle Orthod. .
 20 Overcoming the
Limitations of Aligner
Orthodontics: A Hybrid
Approach
LUCA LOMBARDO and GIUSEPPE SICILIANI
Introduction
Aligners were rst introduced by Kesling1 in 1945 to cor-
rect crowding. Later, Ponitz2 reorted te use o a reo-
able lastic retainer ssi, entsly, or, PA, A. ow-
eer, it was not until te 199s, wen eridan et al.
cobined tese retainers wit interroial reduction
P, tat tey began to gain oularity. en, in 1999,
ia isti and Kelsey irt, togeter wit a couter
secialist, ounded Align ecnology in Palo Alto, A,
A.4 ince tey launced teir nisalign brand into te
aret, te deand or ortodontic aligners as been
growing aong atients esecially adults, tans to teir
estetic roerties and clinical ecacy.5
At rst, aligners were areted as an alternatie to tradi-
tional ed aliances in sile alocclusion cases inol-
ing sligt crowding or inor sace closure. er tie,
oweer, te range o alocclusion cases tat can be
treated by eans o inisible aligners as broadened. lini-
cal researc as deeloed aligner-based solutions or een
cole cases inoling aor rotation o te reolars,
uer incisor torue, distalization, andor etraction sace
closure. esite te claied eciency o aligner treat-
ent, oweer, its clinical otential still reains controer-
sial aong clinicians. ts adocates are coninced by te
clinical eidence arising ro successully treated cases,
wile setics oint to te signicant liitations o te
tecniue, esecially in te treatent o cole aloc-
clusions.-11 rtodontics coanies clai tat aligners
can resole, witout te use o additional tecniues, rota-
tions o 4 degrees at te uer and lower central incisors,
45 degrees in canines and reolars,  degrees in lateral
incisors, and 2 degrees in olars. trusions and intru-
sions o 2.5  ae been acieed in anterior teet, and
root oeents o 4  and 2  ae been reorted in
osterior teet.12
eerteless, ew studies ae been ublised to suort
tese clais, wic are not always suorted by te eeri-
ence o oter clinical ractitioners. n act, soe ortodon-
tists indicate tat te nuber o atients wo reuire soe
unlanned correction or een recourse to ed ortodon-
tics is closer to  to .5 1 Kraitz reorted tat nis-
align aligners ad a ean accuracy o 41 in ters o
acieing lanned outcoes, wit te ost redictable
oeent being lingual contraction 4.1 and te least
redictable etrusion 29..14
n te attet to clariy te situation, Lagraère and
lores-ir15 ublised te rst systeatic reiew on te
subect in 25. ince ten, seeral autors ae roided
udated eidence on aligner ecacy.12,1-1 e ost recent
systeatic reiews into te accuracy o ortodontic oe-
ents acieable wit aligners ae concluded tat tey
are able to roduce distal oeent o te uer olars
and resole anterior crowding issues troug incisor rotru-
sion and by increasing te intercanine, interreolar, and
interolar distances. n te oter and, reoable aligners
are ar less eectie at acieing transerse eansion ia
bodily oeent o te osterior teet. urterore, tey
are unable to eror canine and reolar rotations satis-
actorily, and see to all sort in ters o etrusion oe-
ents and control o oerbite and occlusal contacts.
earing in ind tis eidence, our clinical eerience,
and te eer-growing oularity o aligner treatent, we
ae deeloed a new ybrid aroac using a cobina-
tion o dierent deices to oercoe soe o te ost co-
on liitations o reoable aliances.
Transverse Expansion
of the Posterior Teeth
esearc as sown tat aligners are unable to eror
redictable bodily reolar and olar eansion. igital
setus tend to oerestiate bodily eansion oeents,
and ore tiing tan lanned occurs.19-21 oweer, in
clinical cases ig. 2.1 in wic te osterior sectors are
greatly negatiely inclined, it is ossible to lan uncontrolled
tiing o te uer and lower canines, reolars, and o-
lars. urterore, te sace needed to resole crowding can
be created by using aligners alone ig. 2.2 to eert res-
sure on te lingual suraces o te teet tis iroes te
arcor by signicantly increasing te intercanine, inter-
reolar, and interolar distances ig. 2.. n act, Lo-
bardo et al.22 ae deonstrated tat tis estibulolingual
tiing can be acieed wit a redictability o 2.9.
at being said, in young atients wit transerse de-
cits due to yolasia o te uer aw ig. 2.4, it is not
realistic to eect aligners to aciee seletal alteration.
nly an ortoedic aroac, rst on te deciduous teet
ig. 2.5 and ten ia seletal ancorage2 ig. 2., is
able to noralize te aillary diensions and tereore
275
276 Principles and Biomechanics of Aligner Treatment

Fig. 20.1 Initial intraoral photographs of adult patient with class I

malocclusion dentoalveolar contraction in both arches.

Fig. 20.2 Intraoral photographs during aligner therapy with composite buttons.
 20 • Overcoming the Limitations of Aligner Orthodontics: A ybrid Approach
erit correct erution and iroe te transerse and
sagittal occlusal relationsis. oweer, in suc atients,
aligners ig. 2. can be used as an ecacious tool or
coleting dental alignent and creating accetable inter-
cusidation witout decoensating te class  aloc-
clusion ig. 2..
t is not only in cildren tat suc robles arise, ow-
eer in adult atients,24 te redictability o transerse e-
ansion ia bodily oeent o te reolars and olars is
oor, and ay be daaging in atients wit tin eriodontal
tissues or gingial recession ig. 2.9. ence in adults it is
best to resole issues o seletal aillary contraction ia
surgery or seletal ancorage eanders bone-bone raid
277
Fig. 20.3 inal intraoral photographs after step aligner treatment.
alatal eander ig. 2.1. nly ater te transerse de-
cit as been resoled sould crowding be addressed, and in
suc cases te occlusion can be iroed by eans o align-
ers ig. 2.11, wic can guide te etrusion o te teet
in a controlled asion. is aroac lessens te ris o re-
ature contacts, unwanted estibular oeent, and wors-
ening gingial recession ig. 2.12.
Canine and Premolar Rotation
t as been deonstrated tat te andibular canine is te
ost dicult toot to control wit aligners and tat te
278 Principles and Biomechanics of Aligner Treatment

Fig. 20.4 Initial intraoral photographs of a young patient with sel

etal and dental class III and narrow upper aw.

Fig. 20.5 apid palatal epansion with arms for elaire mas on de Fig. 20.6 ybrid epander with dental and seletal anchorage in up
ciduous second molars. per aw and arms for elaire mas.
 20 • Overcoming the Limitations of Aligner Orthodontics: A ybrid Approach
Fig. 20.7 Intraoral photograph during aligner therapy.
279
aount o rotation actually acieable wit te aillary
and andibular canines is rougly a tird o tat re-
dicted.25 or reolars, te rotation accuracy o aligners
as been reorted witin te range 2.2 to 41..2 e
diculty in derotating cylindrical teet by eans o align-
ers is liely due to te act tat tey are unable to gri tese
teet suciently to generate a orce coule. is ay be
ascribable to oor aligner tting andor ecessie stiness
o te aliance itsel.
uerous otential solutions to tis roble ae been
roosed in recent years. or eale, in a case o crowd-
ing wit a seerely rotated lower canine and uer incisor
ig. 2.1, coosite buttons were alied on te lingual
side o te aligner ig. 2.14 to increase te gri, and
derotation was lanned in only 2 stes. e good elastic-
ity2 and t ig. 2.15 o 22 aligners weden  ar-
tina, ue arrare, taly, in addition to careul striing,
Fig. 20.8 inal intraoral photographs after step aligner treatment.
280 Principles and Biomechanics of Aligner Treatment

Fig. 20.9 Initial intraoral photographs of adult patient with seletal

contraction of upper aw class III tendency and gingival recession in
both arches.

Fig. 20.10 apid palatal epansion with seletal anchorage APA

method. Fig. 20.11 Intraoral photograph during aligner therapy.
 20 • Overcoming the Limitations of Aligner Orthodontics: A ybrid Approach 281

Fig. 20.12 inal intraoral photographs after aligner therapy.

Fig. 20.13 Initial occlusal intraoral photographs of an adult patient with severe rotation of the upper incisors A and right lower canine B.
282 Principles and Biomechanics of Aligner Treatment

Fig. 20.14 Occlusal intraoral photographs during treatment with composite buttons on the lingual surfaces of teeth . . . and ..

roided satisactory alignent, witout recourse to ul-

tile reneents, witin a liited tierae ig. 2.1.
e ae recently deeloed a new ybrid aroac to
increase te redictability o rotations, wic is one o te
aor liitations o aligner treatent.1-1 n cases o rota-
tions o 2 degrees or aboe ig. 2.1, it is ossible to in-
clude icrotubes wit a circular cross section in te setu to
be ositioned across te lingual surace o te rotated teet
ig. 2.1. e setu can be erored in suc a way tat
te aligners coer tese sections witout actually toucing
te ig. 2.19. is enables te clear aligner to guide te
oeent o te teet, eliinate unwanted oeents,
and increase atient coort. y tese eans we acieed
Fig. 20.15 Intraoral photograph during aligner therapy.
correct rotation in only 1 stes witout any reneents or

Fig. 20.16 inal intraoral photographs after step aligner treatment.

 20 • Overcoming the Limitations of Aligner Orthodontics: A ybrid Approach 283

Fig. 20.17 Initial photographs of a young patient with rotation greater than  degrees of left upper canine and left second premolar.

Fig. 20.18 Application of microtubes on rotated mesial and distal teeth.

284 Principles and Biomechanics of Aligner Treatment

A B

C D

Fig. 20.19 Occlusal photographs. A pper arch with thermal iTi . sectional. B pper arch with aligner covering thermal iTi . sectional.
 Lower arch with thermal iTi . sectional.  Occlusal photograph of lower arch with aligner covering thermal iTi . sectional.

coosite buttons. n oter words, tis ybrid aroac
enabled us to iroe bot redictability and treatent
tie ig. 2.2.
Extrusion, Intrusion, and Overbite
Control
According to Kraitz,14 etrusion and intrusion are aong
te least redictable oeents acieable wit clear
aligners only 29. etrusion and 41. intrusion o
te oeents lanned in te setu are acieed at te end
o aligner treatent. oe autors ae deonstrated tat
it is ossible to aciee anterior bite closure using clear
aligners,14 but in te aority o cases tis will inole un-
controlled lingual tiing o te uer and lower incisors,
acieed ia sace creation troug P and transerse
aillary eansion. e diculty in acieing ure etru-
sion is liely due to te oor gri o te aligners on cylindri-
cal teet, wic ay be iroed by te alication o
coosite buttons. oweer, we ae also ad soe suc-
cess in oercoing tis bioecanical liitation, resoling
oen bite using auiliaries eiter beore or during aligner
teray. e ae ound, or eale, wen oen bite in
growing atients is due to bad abits tub-sucing and
as already caused seletal alterations aillary contrac-
tion ig. 2.21, it is better to ot or an ortoedic a-
roac bite-bloc eander wit grille ig. 2.22 to
noralize te uer aw and allow correct erution o te
uer incisors ig. 2.2. en, once tese iroeents
ae been acieed, aligners are te ideal solution or ren-
ing te occlusion ig. 2.24, guiding te eruting teet
into teir roer ositions witin a liited tierae and
wit inial unwanted eects ig. 2.25.
At te oosite end o te sectru, dee bite ig. 2.2
cannot generally be resoled by eans o aligners alone, as
intrusion o te uer and lower incisors is unredictable,
once again resuably due to oor gri on te ancoring
teet. ence, in all cases in wic it is indicated class , not
ecessie estibular oeent o te lower incisors, it ay
be ery useul to eloy class  elastics ig. 2.2. e
eects o tese deices tat are coonly seen as undesir-
able lower olar etrusion and estibular oeent o te
lower incisors enable rotation o te occlusal lane, are-
ciably aiding oening o te bite, and allow correction o te
sagittal relationsis ig. 2.2.
20 • Overcoming the Limitations of Aligner Orthodontics: A ybrid Approach 285

Fig. 20.20 inal intraoral photographs after sevenstep aligner

treatment.

Fig. 20.21 Initial intraoral photographs of young patient with ante

rior open bite and maillary contraction.
286 Principles and Biomechanics of Aligner Treatment
Fig. 20.22 Bitebloc epander with anterior grille.
Fig. 20.23 rontal intraoral photograph after the rst stage of treat
ment with palatal epander and grille.
Fig. 20.24 Intraoral photograph during aligner therapy.
olar istaliation
t as been deonstrated tat aligners are able to distalize
te uer olars wit a ery ig degree o ecacy
rougly  wen te etent o te lanned oeent is
around 2.5 .2 oweer, our clinical eerience as
Fig. 20.25 inal intraoral photographs after step aligner treatment.
sown tat bodily olar distalization is not, in act, acie-
able by eans o aligners, as tey roide only ery liited
root control. ln 215, ang29 deonstrated, in a study o
2 atients wo underwent cone-bea couted toog-
ray  beore and ater aligner treatent, tat irre-
sectie o te tye o ortodontic oeent lanned,
wat was acieed were large crown oeents but ery
sall root oeents. is ade it clear tat te aligners
were acting to tilt te teet rater tan oe te bodily.
it tis in ind, in olar distalization cases
ig. 2.29, it is reerable to lan derotation around te
alatal root, wit distal inclination o te crown rater
tan bodily oeent. Knowing tat derotation o te
uer olar is not sucient to correct class , and ay
cause ancorage loss, it is better to eloy class  elastics
ig. 2.. e eect o tese elastics is to esially incline
te teet in te lower arc, reenting te uer canines
and incisors ro oing esially ig. 2.1.
 20 • Overcoming the Limitations of Aligner Orthodontics: A ybrid Approach 287

Fig. 20.28 inal intraoral photographs after step aligner treatment.

Fig. 20.26 Initial intraoral photographs of a young patient with deep
bite and class II.

Fig. 20.27 Lateral intraoral photograph during aligner therapy com Fig. 20.29 ight initial intraoral photograph of a patient with class II
bined with class II elastics. subdivision and contraction of the upper aw.
288 Principles and Biomechanics of Aligner Treatment
Fig. 20.30 Lateral intraoral photograph during aligner therapy com
bined with class II elastics.
Fig. 20.31 ight lateral intraoral photograph lateral after aligner
treatment.
Fig. 20.32 Left initial intraoral photograph of a patient with class II
subdivision and contraction of the upper aw.
at being said, tere are cases in wic te class  is so
seere tat olar distalization alone is not sucient to re-
sole sagittal issues. n tis atient ig. 2.2, or ea-
le, it would be unrealistic to eect to aciee - distal-
ization ia bodily oeent wit aligners. ence we
decided to eand te uer aw using a raid alatal e-
ander ancored to our iniscrews, ositioned using te
Fig. 20.33 apid palatal epansion and pendulum with seletal an
chorage APA method.
A
Fig. 20.34 Lateral intraoral photographs during aligner therapy A
and combined with class II elastics B.
APA etod,1- in cobination wit a onolateral
endulu ig. 2.. is aroac enabled us to resole
rst te transersal issues and ten te sagittal, uicly,
unobtrusiely, and witout te need or atient coli-
ance. nce class  ad been acieed, a series o 14 aligners
was lanned to close te saces in te uer arc and coor-
dinate te arces ig. 2.4. n tis case, te alication
o aligners in cobination wit class  elastics on te rigt
 20 • Overcoming the Limitations of Aligner Orthodontics: A ybrid Approach
Fig. 20.35 Left lateral intraoral photograph after aligner therapy.
side to roote distalization o te uer reolars and
canines enabled us to treat te alocclusion wit satisac-
tory results oer a sort eriod o tie ig. 2.5.
Conclusions
e scientic and clinical eidence now sows tat aligners
are able to resole alocclusion in a growing nuber o
cases. n te oter and, teir liitations in ters o
acieing transerse eansion ia bodily oeent as
been aly docuented. t also aears tat tey are un-
able to redictably derotate canines and reolars. at is
ore, liitations ae been described or etrusion and in-
trusion oeents and control o oerbite and occlusal
contacts. n te basis o tese ndings, and te nowledge
tat te solution to tese robles cannot be an endless se-
ries o aligners, we roose a ybrid aroac cobining
aligner teray wit dierent ortodontic deices to roide
satisactory and redictable clinical outcoes.
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 etod o alatal iniscrew laceent. EJCO. 215241-4.
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2151419-2.
 Index
age numbers folloe by “f” inicate gures an “t” inicate tables

A Anterior open bite lass  malocclusions, 51

Afferent bers, 253 biomecanics, for correction, 5 entoaleolar iscrepancy, 52, 52f, 53f, 54f
Aging, of polymers, 30 iagnosis, 5 iagnosis, 51
Align appliance, 125–126, 125f, 126f treatment morpologic iscrepancy, 5–60, 61f, 62f, 63f
Aligner alternaties, , 104 preprostetic nee, 60–62, 64f
auxiliaries, 43–47 attacments, 6–7, 6f, 7f toot sie iscrepancy, 53–56, 55f
attacments an pressure areas, 43–45, linec softare esign, 5–6 transerse iscrepancy, 56–5, 56f, 57f,
44f obecties, , 100t, 104, 105t 5f, 5f
interproximal reuction, 45–46 plan, , 104, 105f treatment, 51–52
intraoral elastics, 45 results, 100–102, 101f, 102f, 102t, 105, lear aligner terapy A, 137, 252
temporary ancorage eices, 47 106f, 107f, 10f, 10t case stuy, 240–244, 241f, 242f, 243–244f,
iscoloration, 36 seuence, –100, 100f, 105, 106f 245f, 246f, 247f, 24f, 24f, 250f
extrusion, 1–1, 1f, 1f Arc eelopment, class  malocclusions complex moements, 42
plastics, 17 treatment plan, 51 funamentals recap, 4
Aligner material properties it nisalign, 235
clinical loaing patterns, 40–41, 40f patient compliance, 4
longterm loaing, 37–40, 3f, 40f B surgery rst, 237–240
mecanical properties, 35 eneslier, clinical proceure an rational of, teoretical an practical consierations,
optical canges, 36, 36f 10–11, 11f 43–4
optical material canges, 35 icuspis, it plastic aligners, 1 analysis of moements occurring, 43–4
sortterm mecanical loaing iomaterials, for attacment fabrication, 13 nal position analysis, 43, 43f
multiple cycle, 37, 3f iomecanical conentional attacment, class transitioning, 237, 23–23f, 23f,
occlusal forces, 37  malocclusions treatment plan, 51, 52f 23f, 240f
single, 36–37, 37f olton analysis, 53 it irtual setup softare, 210
ater absorption, 35, 36f racetbase biomecanics, 21 lear aligner treatment A
Aligner ortoontics uccal tipping, 25, 25f class  malocclusions, 66
ancorage, 47 of croing, 52
application, 13 linec softare, 6–6, 3
attacments, 13 C esign, 5–6
basic attacment congurations alcitonin generelate peptie , tools, 52f
anterior extrusion, 1–1, 1f, 1f 252–253 treatment plan, 1f
rstorer control, 1–21, 20f, 21f anine impaction omplementary force ectors, 17, 17f
posterior intrusion, 1, 1f aerse seuelae of, 14 omputerassiste esigncomputerassiste
seconorer control, 21–23, 21f, 22f, clinical case, 157–15, 15f, 15f, 162f, manufacturing AA, 1
23f, 24f 163f, 164f, 165f, 166f onebeam compute tomograpy , 1,
tirorer control, 24–26, 24f, 25f, 26f, early iagnosis an treatment, 14–153, 2f, 153
27f, 2f 152f, 153f aantages, 5
ertical control, 17 late iagnosis, 153–154, 154t AAA, 5
biologic consierations, 4–4 patologic conition, 14 AAA concept, 5
biomaterials, 13 prealence, 14 benets, 6–7, 6f, 7f, f, f, 10f
functions treatment, 14–153, 152f, 153f cepalometrics, 5
eliering preetermine force ectors, planning, 154–157, 154f, 155f, 156f it conentional panoramic
17, 17f, 1f arriere otion 3 Appliance A, 137, examinations, 6
proiing aligner retention, 16, 16f 13 loose raiograpic proceures, 5–6
slipping aoi, 16, 17f A See lear aligner terapy A ortoontic iagnosis an treatment
geometry, 13, 15f  See onebeam compute tomograpy planning, 5
ybri approac  ortognatic surgery, 7
canine an premolar rotation, 277–24, epalometric analysis, 3, 7, f upper airay, 7
21f, 22f, 23f, 24f, 25f erical ertebral maturation , 121 onentional attacments, of aligner
extrusion, intrusion, an oerbite control, emical aging, of polymers, 30, 32–33 auxiliaries, 44, 44f
24, 25f, 26f, 27f lass  elastics, 10 onentional bracet tecniues
molar istaliation, 26–2, 27f, 2f, lass  malocclusions, 123–126, 125f, 126f ortoontic toot moement it, 13, 14f
2f clinical protocol, 67–6 torue moication of, 24, 24f
transerse expansion, 275–277, 276f, elastic effect, 67 reep, 17, 33, 37
277f, 27f, 27f, 20f, 21f extractions, 67 ure of pee, 10–110, 110f
improements, 13 ybri approac in
location, 14–15, 15f, 16f case report, 13–13, 13f, 140f, 141f,
in prerestoratie patients, 16–1 142f, 143–146, 143f, 144f, 145f, D
seuentialiation, 47 146f, 147f eep bite
sie, 15 it istaliing eice, 137–13 case report, 111–114, 111f, 112f, 113f,
translucent composites, 13 manibular aancement, 67 114f, 115f, 116f, 117f, 11f, 11f,
Aligner planning softare, 11–14 maxillary istaliation, 6–7, 6f, 70f, 72f, 120f
Aligner “slipping,” 16, 17f 73f, 74f, 75f, 76f, 77f, 7f, 0f correlation beteen, 10
Alignertoot mismatc, 13, 14f maxillary molar istaliation, 66–67 cure of pee leel, 10–110, 110f
American ental Association ouncil on maxillary molar rotation, 67 enition, 10
cientic Affairs A, 6 ortognatic surgery, 67 treatment strategies, 10
Ancorage management, 47 terapeutic options, 66 upper incisors leel, 110–111

290
 Index 291

ental arces, 3 abial impactions, 157 P

entoaleolar iscrepancy, 52, 52f, 53f, 54f
entofacial ortopeics, 1
ifferential scanning calorimetry , 32
igital maging an ommunications in
eicine , 7
igital imaging tecniues, 11, 11f
igital impressions, 3
igital moels, 1–5, 3f
igital smile esign , 16
istaliation, 67
ouble conentional attacment, 54f
uplex, 56
E axillary molar istaliation, 66–67
lastic aligner eformation, 13, 14f
lastic effect, of class  malocclusions, 67
lastic ear, 67
namel, 3–5
stetic analysis, 16
tanol, 31–32
olution, 1
xtraction
iagnosis, 3, 4f, 5f, 6f
of posterior teet, 5
treatment
plan, 3
progress, 3–7, 7f, f, f, 0f
results, 7–1, 1f, 2f, 3f
F N
abrication process, 32
acial treeimensional scan, 2f
eer aligners, 67
inite element analysis A, 15, 20–21
inite element meto , 44–45
ree gingial graft , 205–207
urcation efects, 207–20
G linec softare esign, 5–6
ingial creicular ui  biomarers,
125
lass transition temperature, 32
lassy material, 31–32
H ptimie attacments, of aligner auxiliaries,
an an rist maturation , 121
orsesoesape geometry, 25–26
ygroscopic expansion, 35
I in clear aligner terapy, 253–254
ncisor control, class  malocclusions treatment
plan, 51
nsufcient force leels, 25–26, 26f, 27f, 2f
nterceptie ortoontics, 121
case reports, 122–123, 123f, 124f, 124t
maxillary expansion, 121–122, 122f
ntermaxillary elastics, 16
nterproximal contacts, 11
nterproximal enamel reuction , 45–46
nterproximal reuction, class  malocclusions
treatment plan, 51–52
ntraoral scans s, 1–5, 3f
nisalign aligners, 13–13
nisalign system, 3
L 152f
abial xe ortoontic appliances, 236–237,
236f
aser scanning, 7–
eone appliance, 125, 125f
oss of tracing, 17
M atologic toot migration , 202
alocclusion, 1
anibular aancement, 126–132, 127f,
12f, 130f, 132f, 133f, 134f
pase, 126
anibular xation, 236–237
axillary istaliation, 6–7, 6f, 70f, 72f,
73f, 74f, 75f, 76f, 77f, 7f, 0f
axillary expansion , 121–122, 122f
axillary molar rotation, 67
axillary transerse eciency, 6
esioistal moements, 210
iniimplants, 10
olar istaliation
aligner ortoontics, in ybri approac,
26–2, 27f, 2f, 2f
upper
in aligner treatment, 10
clinical case, 11–200, 12f, 13t, 14f,
15f, 16f, 17f, 1f, 200f
clinical consierations, 200
olars, it plastic aligners, 1
ucogingial unction , 157
ational ommission on aiation rotection
an easurements, 5
ear infrare  tecnology, 3–5, 4–5f
O lastic foil, 210
penbite treatment
alternaties, , 104
attacments, 6–7, 6f, 7f
for correction, biomecanics, 5
obecties, , 100t, 104, 105t
plan, , 104, 105f
results, 100–102, 101f, 102f, 102t, 105,
106f, 107f, 10f, 10t
seuence, –100, 100f, 105, 106f
44, 44f
ptimie oot ontrol Attacments, 22
rtoontic applications, in polymers, 30
rtoontic pain
biologic mecanisms of, 252–253
clinical consierations, 255–256, 256t
clinical correlates, 252–253
importance of, 252
psycological factors, 254–255
rtoontics, 1
aances in, 16
aligner, 1
iagnosis, 1, 2f
igital eolution in, 1
2 imaging moalities, 5–6
rtoontic toot moement , 42
staging, 47–4
rtoontic treatment See etention
rtoontists, 42
rtognatic surgery, 7, 67, 235
rtopantomograpy , 116f, 120f, 14,
rtoulse, 1–3
ererupte molars, 17
ain, 252
alatal impactions, 157
alatally isplace maxillary canine 
teet, 14
anoramic xray, 147f
enulum  appliance, 13
erioontal isease
clinical case, 214–220, 215f, 216f, 217f,
21f, 21f, 221f, 222f, 223f, 224f,
225f, 226f, 227f, 22f, 22f, 230f,
231f
iagnosis, 205–210
malocclusions relate to, 202, 203f
optimal control, 210–214
ocart, 214
mesioistal moements, 210, 212f
ertical moements, 213–214, 213f
estibulolingual moements, 213
ortoontic moements, 210–214,
212f
ortoontic treatment in, 202, 204f
retention, 214
treatment planning
multiisciplinary team, 205
ortoontic assessment, 20, 20t, 20f,
211f, 212f
patient expectations, 205, 205f
perioontal assessment, 205–20, 205t,
206f, 206t
erioontal ligament  strain, 22, 22f
erioontitis
graes, 205t, 220t
stages, 206t, 21t
 See olyetylene tereptalate glycol

ysical aging, of polymers, 30, 32–33
lastic materials, 42
olyetylene tereptalate glycol , 31,
35
material, cemical structure of, 31f
olymers
cemical aging, 30, 32–33
enition, 30
materials, 30
mecanical stability, 30
molecular structure, 30–32, 31f
in ortoontic applications, 30
pysical aging, 30, 32–33
termal properties, 30–32
olyuretane , 31
material, cemical structure of, 31f
re–manibular aancement pase, 126
 See olyuretane 
R
api maxillary expansion , 121, 122
etention
appliances, 266, 266f, 267f, 26f, 26f
in ortoontic treatment, 25–260
protocol, 260–261f, 260–264, 262f, 263f,
264–265f, 265f, 270–272
specics, 266–270, 270f, 271f, 272f, 273f
eolution, 1
otation control, class  malocclusions
treatment plan, 51
unner, 125, 125f
S
euentialiation, 47
eere entofacial eformity, 235
292 Index
lo maxillary expansion , 122
oft tissue ata extraction, 7–
pace management
in anterior region, 16–16
case stuy, 16–170, 16f, 170f, 171f,
172f, 173f
in posterior region, 170–174, 175f, 176f,
177f, 17f
pecic olume, 31
plintaie maxillary, 236–237
tability, 25–260
tereopotogrammetry, 7–
tress relaxation, 17, 37–3, 40f
ubepitelial connectie tissue graft ,
205–207
upercoole region, 31–32
urgery rst, it aligner terapy, 235–251
T an leeling, 11
angential forces, 16, 17f
eet segmentation, 
emporary ancorage eices As, 47, 5,
157
emporomanibular isorers s
case stuy, 10–14, 10f, 11f, 12f,
13f, 14f, 15f, 16f, 17f, 1f
iagnosis, 17–10
management, 17
treatment plan, 17–10
emporomanibular oint , 7
ensile measurements, 37–3
ermoplastic aligner materials, 40
ermoplastic polymers, 31
ermoplastic polyuretane , 35
oontics See Aligner ortoontics
3 ata integration, 11, 11f
3 facial reconstruction tecniues, 7–, 10f
3 imaging
conebeam compute tomograpy, 5–6
benets, 6–7, 6f, 7f, f, f, 10f
3 ata integration, 11, 11f
3 facial reconstruction tecniues, 7–,
10f
irtual setup, –11, 11f
s See emporomanibular isorers
s
oot alignment
after aligner seuence, 13, 14f
oot isplacement patterns, of posterior
teet, 22, 22f
oot sie iscrepancy, 53–56, 55f
oottootgingia segmentation, 
orue moication, of anterior teet, 24
racing superimposition, 116f
ransition pase, 126
ranserse eciency
correction of, 24
maxillary, 6
ranserse iscrepancy, 56–5, 56f, 57f,
5f, 5f
umor necrosis factora a, 252–253
U
pper molar istaliation See also olar
istaliation
in aligner treatment, 10
clinical case, 11–200, 12f, 13t, 14f,
15f, 16f, 17f, 1f, 200f
clinical consierations, 200
prigting moment, of posterior teet, 22f
V
ertical moements, 213–214
estibulolingual moements, 213
iscoelasticity, 31–32
iscoelastic material, mecanical beaior
of, 37
W
ater absorption, of aligner material
properties, 35, 36f
it of eratinie gingia , 20
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