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Correction of Incisal Crowding Joe Hannah, DDS

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A 53-year-old female presented with a Class II occlusion, subdivision right, and minor to moderate anterior crowding, and a mandibular midline discrepancy (Figs. 1-10). The patient was not interested in full occlusal correction, and wanted to be treated with an aligner system for cosmetic tooth alignment. In addition to seeking treatment for cosmetic reasons, she was concerned that her teeth would continue to shift and crowd more as she aged. The patient stated that she had noticed shifting of her teeth over the past several years, which is, in part, what caused her to seek treatment. The patient decided to go with aligner therapy because she knew she would occasionally be able to remove them, and she also thought they would be more convenient to care for than traditional wires and brackets.



She had several areas of mild gingival recession and slight alveolar bone loss in the maxillary and mandibular posterior right quadrants. Her periodontal condition was deemed good. No contraindications to orthodontic treatment were present. We informed the patient about AcceleDent, a removable appliance that has been shown to accelerate tooth movement by generating small vibrations called micropulses (Fig. 11). It has also been reported by previous users to reduce the discomfort caused by tooth movement. The patient would make her decision to use based upon the number of aligners planned for her treatment.

Treatment sequence
We delivered the starter aligners and informed the patient of the wear sequence. We advised her that the first day of orthodontic treatment could come as a shock to some patients, and that the pressure initially applied to the teeth could potentially cause soreness. We also informed the patient that the starter aligners ClearCorrect provided would instead begin with a gentle pressure, before moving on to the first treatment aligners, which would include a more aggressive movement. The patient's treatment plan included a total of 20 total aligners over 60 weeks of treatment time. ClearCorrect delivers their aligners in phases, with each phase consisting of four sets of aligners (i.e., 1A, 1B, 1C, 1D), which makes treatment administration more flexible should changes to treatment be necessary. Additionally, the patient elected to order AcceleDent, with the estimate of 30 to 35 weeks of treatment (as opposed to 60 weeks treatment time without). Each aligner would be worn for one-and-a-half weeks instead of the traditional three week wear schedule. Engagers were placed on teeth #5, #10 and #28 at the beginning of aligner #3 (1C). An additional engager for tooth #21 was planned for aligner #9 (3A). Engagers (otherwise known as attachments) are composite additions to the teeth. They are placed by the use of templates and assist in specific tooth movements. Having specific information in regard to engagers at the onset of treatment is very beneficial to my patients, as they then know in advance the treatment planned for them and what to expect.

Specific treatment plan
My treatment preferences submitted included proclination, arch expansion and improvement of the patient's overbite. No IPR was prescribed. As soon as my patient elected to use AcceleDent, we contacted ClearCorrect to ask that the next phase of aligners be delivered within our new shortened delivery schedule, a request that was promptly met.

Treatment progress
We had eight aligner fitting appointments over the course of eight months. At the conclusion of aligner #8 (2D), the maxillary lateral incisors were not fully seating into the aligner. The patient's compliance was excellent, but even with the use of chewies to help with the incisor movement, we elected to add composite buttons on the facial and lingual of #7 and #10, at the gingival margin. The aligners were relieved approximately 1.5mm incisal to the buttons, and a 3/16", 3.5 medium light oz. elastic was worn from the labial to the lingual to extrude the laterals. The elastics were twisted several times to increase their force (Fig. 12), and the patient continued to wear aligner #8 (2D) for an additional two weeks.
We continued with elastic wear on aligners 9(3A) and 10(3B), and the incisors were fully seated again as she progressed to aligner #11(3C). Several weeks prior to the completion of her last aligner, the decision was made to order a revision phase, the cost of which was included with the original ClearCorrect Unlimited treatment option, as the tooth alignment was not yet ideal. Four additional aligners were delivered and we finished her treatment six weeks after the revision aligners were received (Figs. 13-21). The patient continued with her AcceleDent wear throughout the entire treatment period.

Retention
We opted for maxillary and mandibular bonded fixed retainers, .0175 respond wire, and additionally made in-house, vacuum-formed clear retainers to be worn at night. The patient will return as needed, or in six months for a follow-up evaluation.

Summary
There were a total of 18 appointments, including the records' appointment, starter aligner fitting, two additional appointments to add the composite buttons, and a revision impression appointment. The patient was very happy with her result. Her tooth alignment finished nicely and she remained with a Class II posterior occlusion on the left, with a similar midline discrepancy. Her active treatment time shortened from the normal 72 week treatment length (24 aligners worn for three weeks each) to an active treatment time of 40 weeks.
The accelerated aligner therapy met the patient's needs and desires. She was happy with her decision to use AcceleDent, and reported minimal discomfort during treatment. ClearCorrect proved a good choice for the patient as she reported that she did take her aligners out for special occasions, they were very easy to care for and she is no longer worried about the shifting and crowding that she saw occurring over the last several years.

Dr. Joe Hannah is a native Kansan who grew up in the town of Lyons. Growing up in a small town, Dr. Hannah appreciates the personal aspect of meeting people and getting to know his patients and their families. Dr. Hannah attended UMKC Dental School but left the area to complete his orthodontic residency at the University of Louisville. Dr. Hannah is a diplomate of the American Board of Orthodontics, a member of the American Association of Orthodontists and past president of both the Kansas State Association of Orthodontists and the Greater Kansas City Society of Orthodontists.

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