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08 May 2019

3D CAD/CAM planning of alignment treatment for complex orthodontic case

Author: Rafi Romano


The following clinical case presents complex aesthetic and functional case of sever deep bite with relapse of previous orthodontic treatment in childhood, combined with periodontic involvement. We used 3D technologies to scan, simulate, plan and treat the patient in very short time with predicted results and comfortable invisible orthodontic appliance (figs. 1, 2).

  • Figs. 1, 2 Frontal view of the smile and the occlusion. Note the unaesthetic appearance due to the deep bite and anterior diastema

    Figs. 1, 2 Frontal view of the smile and the occlusion. Note the unaesthetic appearance due to the deep bite and anterior diastema

  • <p>Fig. 2</p>

    Fig. 2

CLINICAL CASE
G.L., 51 years old patient, presented to the clinic with Class I malocclusion, deep bite with complete coverage of lower incisors, big median diastema between teeth #11 and #21, lack of interdental papilla and poor oral hygiene (figs. 3, 4).

  • Fig.3: Frontal view of the occlusion with open mouth. Note the 2 planes of occlusion caused by anterior extrusion of the lower incisors and the abrasion to the incisal edges

    Fig.3: Frontal view of the occlusion with open mouth. Note the 2 planes of occlusion caused by anterior extrusion of the lower incisors and the abrasion to the incisal edges

  • Fig.4:Lateral view of the occlusion. Note the enlarged OJ and the deep bite causing trauma to the anterior teeth

    Fig.4:Lateral view of the occlusion. Note the enlarged OJ and the deep bite causing trauma to the anterior teeth

Lower incisors erupted vertically and created 2 planes of occlusion and exaggerated curve of spee in the lower arch. The upper lip “pushed” the anterior incisors lingually and consequently the bite was deepened. Oral hygiene is poor mainly due to the crowding of the lower incisors. The upper diastema resulted in the loss of the interdental papilla between the central incisors (figs. 5, 6).

  • Figs. 5, 6 Occlusal view of the maxilla and mandible. Arches are constricted with spaces in the upper arch and moderate to severe crowding in the lower arch

    Figs. 5, 6 Occlusal view of the maxilla and mandible. Arches are constricted with spaces in the upper arch and moderate to severe crowding in the lower arch

  • <p>Fig. 6</p>

    Fig. 6

Patient had gone through previous orthodontic treatment with extraction of upper first premolars (#14, #24). Space between #11-#21 is slowly opened during the years and space start to develop distally to the upper lateral incisors. Lower incisors are hitting traumatically the palate creating proliferation of the epithelium and constant inflammation. Lower anterior crowding is around 4.5 mm (#33-#43) (figs. 7, 8).

  • Figs. 7, 8 3D digital planning of the treatment. Movement was divided to 36 aligners (one week each

    Figs. 7, 8 3D digital planning of the treatment. Movement was divided to 36 aligners (one week each

  • <p>Fig. 8</p>

    Fig. 8

Treatment was planned with Clincheck® Software of Invis- align® (Milano, Italia). 36 aligners were prescribed for 40 weeks (9 months). Patient was monitored every 2 months with photos, oral hygiene mechanical cleaning and periodontic examination. Lower teeth were proclined, upper and lower arches were slightly expanded and upper and lower anterior teeth were intruded to help opening the bite (fig. 9).

  • Fig. 9 Patient with the aligners during the treatment. Note the perfect fit of the aligner’s edges to the teeth which ensure that all movements that were planned actually happened.

    Fig. 9 Patient with the aligners during the treatment. Note the perfect fit of the aligner’s edges to the teeth which ensure that all movements that were planned actually happened.

In this figure, patient during the Invisalign treatment. Note the perfect fit of the aligners due to correct planning and implementation of biomechanics rules together with very compliant patient (figs. 10, 11).

  • Figs. 10: Frontal view of the smile at completion of the treatment. Note the dramatic positive change in all aesthetic standards of the smile

    Figs. 10: Frontal view of the smile at completion of the treatment. Note the dramatic positive change in all aesthetic standards of the smile

  • Figs. 11: Lateral view of the smile at completion of the treatment. Note the dramatic positive change in all aesthetic standards of the smile

    Figs. 11: Lateral view of the smile at completion of the treatment. Note the dramatic positive change in all aesthetic standards of the smile

It is not every case that we consider a “life change”... this treatment for this patient was so important and the change we have achieved in his smile, function and aesthetics is dramatic not to speak on the fact that we have probably saved his teeth from further destraction (figs. 12-16).
Patient received fixed retainers for anterior teeth and re- movable clear aligners for night wear. 

  • Figs. 12-16 Final photos of the teeth after treatment with 3-3 fixed retainers bonded on upper and lower anterior teeth

    Figs. 12-16 Final photos of the teeth after treatment with 3-3 fixed retainers bonded on upper and lower anterior teeth

  • Fig. 13

    Fig. 13

  • Fig. 14

    Fig. 14

  • Fig. 15

    Fig. 15

  • Fig. 16

    Fig. 16

FINAL CONSIDERATIONS
In summary, careful treatment planning, with advanced accurate and predictable 3D clear aligners’ technology enable us to bring this complex case into completion in less than 9 months.

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