Invisalign® clear aligner case report series

Teen extraction case using Invisalign aligners

Extraction treatment of a severely crowded Class II subdivision malocclusion with ectopic canines and
anterior crossbite using Invisalign aligners.

Dr. Shen-Chieh Lin (Hsinchu, Taiwan)

Dr. Lin received his D.D.S. from Chung Shan Medical University in 2001 and a master’s degree in clinical orthodontics from
National Yang Ming University in 2006. He manages his private practice in Hsinchu, Taiwan. He started to treat patients with
the Invisalign System beginning in 2009 and has been a Diamond status provider since 2016. Not only does Dr. Lin provide
comprehensive orthodontic treatment with Invisalign aligners to patients of all ages, he also cooperates with other specialists
on complex interdisciplinary cases. Dr. Lin is a diplomate of the Taiwan Board of Orthodontics and he has been a clinical
speaker on Invisalign treatment since 2015.

Patient: Initial records:

Age: 17 year-old female

Chief concern: Severe crowding and a desire

to improve her facial profile and dental function.

Diagnosis:

• Permanent dentition
• Right side: Class III canine, Class II molar
• Left side: Class I canine (ectopic),
Class I molar
• Straight facial profile
• Class III tendency skeletal relationship
• Anterior crossbite of the upper lateral incisors
• Severe upper crowding (blocked-out upper
right second premolar)
• Severe lower crowding (unfavorable root axis
of the lower left canine)
• 3rd molars present, but unerupted

The opinions expressed in this case report are those of the author and may not reflect those of Align Technology, Inc. The author was paid an honorarium by Align Technology, Inc.
in connection with writing this report. 1
 Invisalign® clear aligner case report series

Cephalometric values1: Initial ClinCheck treatment set-up and staging:

For maximum tooth movement control in this extraction case, we will
Measurement Initial value Norm # of deviations try to do as little tooth translation movement as possible. For example,
from norm in the lower right quadrant, we decided to sequentially distalize the molars
by a few mm into proper interdigitation (supported with Class III elastics),
SNA 78.3 82 -1.2 instead of extracting a bicuspid and translating all the lower molars mesially.

SNB 78.6 80 -0.4 Invisalign aligner features used:

ANB -0.3 2 -0.9 • Optimized extrusion attachment (G3) on buccal of UL2;

L1-MP (IMPA) 94 90 0.8 • Power ridge feature (G3) on buccal of LR1, LR2, LL1, and LL2;

Interincisal 129.8 135 -1.0 • Optimized root control attachments (G4) on buccal of UL1, LR4, and LL4;
angle
• Optimized multiplane attachment (G7) on buccal of UR2;
MP-FH (FMA) 22 22 0
• Precision cuts on LR3 and UL3;

Treatment goals: • Button cutouts on UR6 and LL6;

1. Relieve the dental crowding . • Virtual pontics for the UL4 and LL5 extraction spaces (no virtual pontic
for UR5 is needed since a large interdental space will not be present
2. Correct the right side to Class I canine relationship and full Class II
after the extraction);
molar relationship.
• Conventional rectangular attachments for aligner retention.
3. Center the dental midlines.

4. Correct the crowding and anterior crossbites while maintaining

proper alveolar bone support for the teeth.

5. Improve the vertical position of the canines on the left side and
the root axis of the lower left canine.

6. Maintain good oral hygiene habits during and after treatment.

Treatment plan:
1. Extract the upper right second premolar, the upper left first premolar,
and the lower left second premolar. The extraction procedure will be
done after the scan is taken once the ClinCheck® set-up finalized.
These teeth will be virtually extracted in the digital set-up and virtual
pontics will be added to strengthen the aligners (no pontic filler was
planned in the aligners since the extraction spaces were not located
in an esthetic region). See Clinical Discussion for extraction pattern
details.

2. Class II elastics on the left side and Class III elastics on the right side.
See Clinical Discussion for elastics details.

3. Re-scan the patient with the iTero® scanner for additional aligners
as needed for detailing and finishing.

4. Retain the treatment results using Vivera® clear retainers.

Our retention instructions are: full time wear for 6 months after
completion of treatment and then only at night after 6 months.

1
Both the initial and final cephs were traced by an outside lab service (RMO e-ceph®). Align data on file. Standard deviations of 5°, 5°, and 3° were used for L1-MP,
interincisal angle, and MP-FH (FMA), respectively.

The opinions expressed in this case report are those of the author and may not reflect those of Align Technology, Inc. The author was paid an honorarium by Align Technology, Inc. 2
in connection with writing this report.
 Invisalign® clear aligner case report series

Interim actions after initial set of aligners were completed:

After the initial aligners phase, sectional fixed appliances were used for 4 months on the lower
left canine, first premolar, and first molar for better root position. We bonded .022 slot self-ligating
brackets and used an 0.14” round NiTi sectional wire initially, followed by a .016 x .022” rectangular
NiTi sectional wire. The upper right first molar was also tipped mesially, but not enough for us to
need sectional appliances. For that tooth, we would use triangular elastics after additional aligners,
if needed. The sectional appliances were worn at the same time as the upper and lower aligners,
but with the lower aligners trimmed to remove the part distal to the lower left canine.

Staging for the initial aligners: 36 active + 14

passive + 3 overcorrection aligners in the upper
arch and 50 active + 3 overcorrection aligners
in the lower arch.

Scan images of the patient for additional aligners (after the sectional appliances phase).

The opinions expressed in this case report are those of the author and may not reflect those of Align Technology, Inc. The author was paid an honorarium by Align Technology, Inc. 3
in connection with writing this report.
 Invisalign® clear aligner case report series

Additional Aligners ClinCheck® treatment set-up and staging:

Progress records:

Staging for the additional aligners: 19 active + 3

overcorrection aligners in the upper arch and 15
active + 4 passive + 3 overcorrection aligners in
the lower arch.

After the additional aligners were worn, triangular elastics were used for 3 months on bonded buttons,
to improve the interdigitation of the posterior teeth. During the triangular elastics phase, the aligners
were trimmed to not include any teeth with buttons bonded.

The opinions expressed in this case report are those of the author and may not reflect those of Align Technology, Inc. The author was paid an honorarium by Align Technology, Inc. 4
in connection with writing this report.
 Invisalign® clear aligner case report series

Final records:

The opinions expressed in this case report are those of the author and may not reflect those of Align Technology, Inc. The author was paid an honorarium by Align Technology, Inc. 5
in connection with writing this report.
 Invisalign® clear aligner case report series

Cephalometric values:

Both the initial and final cephs

Measurement Initial value Final value Norm # of deviations from norm
were traced by an outside lab
(final)
service (RMO e-ceph®). Data on
file. After treatment, the lower
SNA 78.3 77.7 82 -1.3
incisor inclination and vertical
SNB 78.6 78.1 80 -0.5 dimension remained the same
as before, and no significant
ANB -0.3 -0.4 2 -0.9 change to ANB angle was
measured. The interincisal angle
L1-MP 94 94 90 0.8 was improved by 3.5 degrees.

Interincisal angle 129.8 133.3 135 -0.3

MP-FH (FMA) 22 22 22 0

Treatment summary: • Emergency visits: none

• Number of aligner stages used: • Appointment scheduling:

– Upper: 36 (initial) +19 (additional) – The patient was seen every 2 months (8 aligner stages
dispensed per visit). Aligners were changed weekly.
– Lower: 50 (initial) +15 (additional)
– Note: Since COVID-19, our Invisalign patients are being seen
• Aligner change interval: every 7 days for initial and additional aligners
every 3 months (12 aligner stages dispensed per visit), as long
• Aligner wear compliance and oral hygiene: very good as good aligner wear compliance is observed. Aligners are still
• Treatment time: 17 months (including the time between the initial and being changed weekly.
additional aligners)
• Auxiliaries used:
– Sectional fixed appliances for 4 months after the initial aligners:
.022” slot self-ligating brackets on the lower left canine, first premolar,
and first molar (.014” NiTi + .016x.022 NiTi sectional wires).
– Elastics:
– Right side: Class III elastics with precision cuts (LR3) and
a button cutout (UR6), using 1/4” 6 oz. elastics full-time
throughout treatment.
– Left side: Class II elastics with precision cuts (UL3) and button
cutout (LL6), using 1/4” 6 oz. elastics full-time during the initial
aligners, and then Class III elastics with precision cuts (LL3)
and a button cutout (UL6) during the additional aligners.
– Triangular elastics for 3 months on buttons bonded to the first
molars and the UL + LR second premolars (1/4” 3.5 oz. initially,
then 1/4” 6 oz. elastics)

The opinions expressed in this case report are those of the author and may not reflect those of Align Technology, Inc. The author was paid an honorarium by Align Technology, Inc. 6
in connection with writing this report.
 Invisalign® clear aligner case report series

Clinical discussion:
This was a challenging extraction treatment of a Class II, subdivision Supplemental section: Using the ClinCheck tooth
right malocclusion. At the end of treatment, the severe crowding, anterior movements table to help treatment plan cases for
crossbite, and ectopic canines were corrected, with good bite interdigitation
better outcomes.
and parallel roots achieved. Both canines were Class I relationship at the
end of treatment, and the dental midlines were centered. The patient was
compliant with wearing her aligners and elastics as instructed, and she The tooth movements table in the ClinCheck software is a
maintained good oral hygiene throughout treatment. very useful feature for viewing the specific amounts of tooth
movement prescribed in the treatment plan. To view this table,
The patient and her parents chose Invisalign aligners instead of regular you select “Tooth Movements Table” under the “Tools” button:
braces because they were concerned about comfort, esthetics, and having
good oral hygiene during treatment. Even with the sectional braces and
the triangular vertical elastics with buttons being used, all of their main
concerns were addressed and we were happy with the excellent results.

Success was achieved because we carefully designed the set-up using

the ClinCheck® software so that the tooth movements planned were
compatible with the aligner’s biomechanical strengths (e.g., sequential
distalization, relief of crowding, and space closure). The extraction pattern
we used for this case was specifically chosen because of its compatibility
with aligner treatment. An alternative extraction pattern would have been
to extract the LR4 to correct the Class III canine. However, we chose to
distalize the lower right side by 3 mm instead of mesializing the LR6 and
LR7 by 3 to 4 mm, because mesialization would have been more challenging.
We also recommended extraction of LR8 prior to distalization, but she
wanted to avoid doing this and declined. Given the patient’s young age, On the left side of the table, you can choose to display either
we felt that distalization without extraction was still possible, but told her the upper arch or the lower arch measurements, and on the right
that if it was not working out, then the LR8 extraction would be required. side of the table, you can choose to display either crown-based
On the left side, we decided to extract LL5 instead of LL4, because the measurements or root-based measurements:
left side was mild Class II initially, and we wanted to let the lower left
molars slip forward a little bit and not let the lower midline shift towards
the left side too much.

Our use of attachments for this case was mostly for aligner retentiveness
by using conventional rectangular attachments. As a result, we only used
optimized attachments for extrusion (UR2, UL2) and for root tip control
(UL1, LR4, LL4). For similar bicuspid extraction cases in the future, we are
inclined to use the default optimized attachments along with the SmartStage®
technology for better control of the root positions, to hopefully avoid
sectional fixed appliances and vertical elastics with bonded buttons as
part of the treatment. In the lower left quadrant, we used sectional appliances
as a simple way to upright roots that had tipped during the canine and first Upper / lower arch measurements
bicuspid retraction. The Invisalign G6 solution is designed for first bicuspid
extraction cases, but the principle of trying to avoid crown tipping of
adjacent teeth into the extraction site during anterior retraction is similar
for second bicuspid extractions, so we would try it to see if sectional
appliances could be avoided or shortened in duration, by first using the
Invisalign optimized attachments designed for better control of root tip.

Crown / root measurements

The opinions expressed in this case report are those of the author and may not reflect those of Align Technology, Inc. The author was paid an honorarium by Align Technology, Inc. 7
in connection with writing this report.
 Invisalign® clear aligner case report series

Supplemental section: Using the ClinCheck® tooth movements table to help treatment plan cases for better
outcomes. (Cont.)
The tooth movements table lets you see what kinds of movements have been programmed into your set-up. We use these measurements as
feedback, when determining where best to position the teeth in the ClinCheck set-up. Without this feedback, we would not be able to quantify
the specific movement components in our set-up, and treatment planning would be much more challenging.

The types of movements I want to pay close attention to are any large rotations of canines or bicuspids, any large extrusions, and any large
bodily translations. For example, in the example below, the upper left canine was ectopically erupted, but we wanted to minimize the extrusion
along the long axis of the tooth in the treatment plan. Most of the correction we planned in the set-up was through lingual crown tip, because
that movement would be easier to achieve with aligners. If we built a larger extrusion component into the set-up, then we might need to use
buttons and elastics as part of the treatment plan.

Here, the upper left canine was in infraocclusion, but only 0.9 mm of extrusion along the long axis was needed. The remainder of the correction
could be accomplished by 21.2 degrees of lingual crown tip, which is more predictable.

In a second example, below, the lower left canine was initially rotated 47.7 degrees distal-out. This would be difficult to fully rotate into place in
its current location because of the crowding. However, if a distal space is created by extracting the lower-left second premolar, then 2.7 mm of
lingual translation (plus 3.5 mm distal translation) with 14.3 degrees of lingual crown tip is needed to rotate the canine into the arch. We chose
this combination over trying to rotate the canine in place without extraction, because we felt these movements were more compatible with the
aligner’s biomechanical strengths.

We can also use the interactive set-up tools in the ClinCheck software to move individual teeth until the tooth measurements are more
compatible with our preferences. However, if you make “interactive” changes to the set-up, you will need to select “Doctor” under “Final Stage”
on the top right side of the table to view the tooth movements.

If you have Invisalign treatment results from your practice that you would be interested in sharing with your
peers, please submit your cases at the Align Global Gallery at:

submit.InvisalignGallery.com

The opinions expressed in this case report are those of the author and may not reflect those of Align Technology, Inc. The author was paid an honorarium by Align Technology, Inc.
in connection with writing this report.
For additional details about this treatment, including the actual 3D ClinCheck® treatment plan used, please visit: https://global.invisaligngallery.com/treatment/t-805/

© 2020 Align Technology, Inc. All Rights Reserved. Align, the Align logo, Invisalign, the Invisalign logo, iTero, iTero Element, and ClinCheck, among others, are trademarks and/or service marks
of Align Technology, Inc. or one of its subsidiaries or affiliated companies and may be registered in the U.S. and/or other countries. MKT-0005498 Rev A 8