CLINICAL EBOOK SERIES PEER-REVIEWED

ORTHODONTICS
JUNE 2024 • VOLUME 12 • NUMBER 233

2 C E C R E D I T S

Teeth Bleaching Efficacy During Clear Aligner

Orthodontic Treatment
Rhoda J. Sword, DMD; and Van B. Haywood, DMD

C A S E R E P O R T

Anterior Intrusion With Clear Aligners

Andrew Ferris, DDS, MS

SUPPORTED BY AN UNRESTRICTED GRANT FROM CARESTREAM DENTAL • Published by BroadcastMed LLC © 2024
 Making the Most PEER-REVIEWED

of Clear Aligners
PUBLISHER
BroadcastMed LLC

T
SENIOR EDITORIAL DIRECTOR – DENTAL
C. Justin Romano
justin.romano@broadcastmed.com
he popularity of aligner therapy as an alternative to
SR. EDITOR – CDEWORLD
fixed orthodontics has become common knowledge Vicki J. Hoenigke
among dental professionals. The clear thermoplas- vicki.hoenigke@broadcastmed.com

tic aligners, or trays, are generally found to be more EBOOKS MANAGER

Susan Tarrant
esthetically pleasing than traditional wires and brack- susan.tarrant@broadcastmed.com
ets, and their removability and design offer convenience and a level
DESIGN LEAD
of comfort that many patients prefer. However, although clear aligner Maureen Ricco
therapy is widely considered an excellent option for correcting mild to maureen.ricco@broadcastmed.com

moderate malocclusions, fixed orthodontics have often been thought CDEWorld eBooks and Orthodontics are published by Broadcast-
the better choice for some more complex cases. In this edition of the Med LLC.

thematic CDEWorld eBook series, we consider how the applications
of clear aligner therapy are currently widening—through the use of
aligner trays for tooth-bleaching during orthodontic treatment, as well
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as through new technological developments and approaches that make
aligner therapy suitable for some complex cases.
Our first article is a continuing education article on a method for
teeth bleaching that is performed during clear aligner therapy. This
article describes how teeth bleaching can be expedited by the use
of clear aligner trays, which are used concurrently for the patient’s
orthodontic therapy. The effectiveness of bleaching using aligner
trays, especially on areas of the teeth that are covered by the com-
posite attachments employed in aligner therapy, is also discussed.
This article features a case study demonstrating the combined use
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specified articles provided the base fee is paid directly to CCC.
The views and opinions expressed in the articles appearing in this
publication are those of the author(s) and do not necessarily reflect
the views or opinions of the editors, the editorial board, or the
publisher. As a matter of policy, the editors, the editorial board, the
publisher, and the university affiliate do not endorse any products,
medical techniques, or diagnoses, and publication of any material in
this e eBook should not be construed as such an endorsement.
WARNING: Reading an article in CDEWorld and Orthodontics
does not necessarily qualify you to integrate new techniques or
procedures into your practice. BroadcastMed LLC expects its
readers to rely on their judgment regarding their clinical expertise
and recommends further education when necessary before trying
to implement any new procedure.

of these bleaching and orthodontic modalities.

In addition, this eBook includes a case report article on the use of CHIEF EXECUTIVE OFFICER
clear aligner therapy to achieve anterior intrusion in a patient with Charlie Lee
charlie.lee@broadcastmed.com
a deep class II bite. In this patient with severe mandibular crowd- VICE PRESIDENT – DENTAL SALES
ing and a severe two-plane occlusion, the use of traditional fixed Matthew T. Ingram
matt.ingram@broadcastmed.com
appliances was deemed to be very challenging, and clear aligner
DIRECTOR – BUSINESS DEVELOPMENT
therapy was adopted to fully intrude the lower anterior teeth while Molly Borsellino
developing the arch forms. molly.borsellino@broadcastmed.com
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1 CDEWorld EBOOK SERIES June 2024 | Volume 12 Number 233 www.cdeworld.com

 CONTINUING EDUCATION TEETH BLEACHING DURING CLEAR ALIGNER TREATMENT

Teeth Bleaching Efficacy During Clear

Aligner Orthodontic Treatment
Rhoda J. Sword, DMD; and Van B. Haywood, DMD

ABSTRACT: Clear aligner treatment has become popular for many orthodontic cases
that ordinarily would have required traditional orthodontic brackets and wires. One of
the motivating reasons for patients to use clear aligner therapy is to improve their
esthetic appearance, which typically is the same motivation for teeth bleaching, thus a
combination of the two treatments may be desirable. The case report presented dem-
onstrates bleaching concurrent with clear aligner treatment. A concern about bleaching
during such treatment is that the areas on the tooth under the composite attachments,
or buttons, used to retain the clear aligner trays may remain unbleached. However, due
to the small molecular size of the bleaching material agent and its ability to permeate
the tooth, the area under the attachment will be bleached as well. With this understand-
ing, a practitioner can treat patients more efficiently by being able to complete bleaching
treatment simultaneously with clear aligner treatment.

LEARNING OBJECTIVES

• Describe the benefits of • Discuss patient concerns about • Discuss how teeth bleaching
combining clear aligner therapy combining clear aligner therapy material is administered using
with teeth bleaching treatment with teeth bleaching treatment clear aligner trays, as explained
in the case studies

T
he orthodontic treatment process
known as clear aligner therapy has
become a popular treatment modality
for many cases that would have other-
wise needed traditional orthodon-
tic brackets and wires.1 With the clear aligner
method, patients have the flexibility of remov-
ing the aligner trays during meals and for clean-
ing while still undergoing orthodontic treat-
ment. Although patient compliance has the
potential to be slightly compromised depend-
ing on the user’s ability to remove the trays,
this method is quite popular with patients and
offers several inherent benefits, including the
DISCLOSURE: Dr. Haywood periodically receives grant/research and product support from Ultradent Products, Inc.
fact that the challenge of brushing and floss-
ing around traditional orthodontic brackets and
wires is eliminated. With the tray removed, the
patient can brush and floss as usual, which can
alleviate the concern regarding the formation
of white hypocalcified areas that often accom-
pany the hygiene issues affiliated with tradi-
tional orthodontic treatment.
The clear aligner technique employs a fairly
rigid custom-fitted tray that is used to perform
the movement of the teeth; composite attach-
ments, or buttons, are bonded to several teeth
to aid in the retention of the orthodontic tray.
Although patients undergoing this treatment

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 CONTINUING EDUCATION
Research has shown that the use of 10% carbamide
peroxide in bleaching has resulted in improved
gingival scores as well as tooth bleaching
do not have to contend with the drawbacks as-
sociated with brackets and white spot lesions,
the composite attachments on the teeth can
compromise oral hygiene due to their irregu-
lar shapes protruding from the teeth.2
One of the motivating reasons for orthodon-
tic treatment is improved esthetics. A better es-
thetic appearance is also a prime motivation for
teeth bleaching; therefore, combining the two
treatments may be beneficial to patients for sev-
eral reasons. Patients undergoing clear aligner
treatment already have aligner trays, so a pos-
sible approach to bleaching for these patients
would be the use of their existing tray as the de-
livery mechanism for bleaching material. This
approach can be highly cost-effective, because
separate impressions and trays would not have
to be made for a patient interested in bleach-
ing. Although some advocates of bleaching en-
courage the use of scalloped trays with reser-
voirs for the bleaching material, studies have
shown that bleaching with non-scalloped, non-
reservoir trays using 10% carbamide peroxide
bleaching material is just as safe and also can
conserve bleaching material.3-5 Hence, these
trays could accommodate bleaching treatment
with 10% carbamide peroxide. Also, bleaching
during clear aligner treatment can improve oral
hygiene and further minimize the potential for
white spot lesions.6
One possible concern among patients bleach-
ing during clear aligner treatment is the poten-
tial for a lack of color change on the portion of
the tooth covered by the composite attachment.
The concern is that upon removal of the attach-
ment, or button, the area of the tooth underneath
3 CDEWorld EBOOK SERIES June 2024 | Volume 12 Number 233
TEETH BLEACHING DURING CLEAR ALIGNER TREATMENT
it would not be bleached, leaving a discolored,
yellowish spot on the tooth. The purpose of
this article is to allay concerns of having a yel-
lowish unbleached area on the tooth where the
composite button is located when bleaching
teeth during clear aligner orthodontic therapy.
Case 1
A 23-year-old male patient undergoing clear
aligner treatment presented with composite
buttons on teeth Nos. 6, 12, 21, and 28 and
was interested in bleaching to lighten the
shade of his teeth. He was taking no medica-
tions, and his medical and dental histories were
noncontributory.
The patient did not realize he had the choice
of undergoing bleaching treatment either con-
current with clear aligner therapy or after its
completion. It is often presumed that bleaching
requires a particular tray with reservoirs and
scalloping. However, when using 10% carb-
amide peroxide, any tray design that closely
approximates the teeth and extends onto the
tissue can be used for bleaching with this low
concentration of material. Originally, 10%
carbamide peroxide was used as an oral anti-
septic designed to be put on the gingival tis-
sue. Research has shown that the use of 10%
carbamide peroxide in bleaching has resulted
in improved gingival scores as well as tooth
bleaching,7,8 thus any reasonable tray design
can be effective. Another frequent concern is
whether there will be “spots” left on the por-
tions of the tooth that are covered by an ortho-
dontic bracket; however, research has shown
that the peroxide penetrates completely through
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 CONTINUING EDUCATION TEETH BLEACHING DURING CLEAR ALIGNER TREATMENT

the enamel and dentin, and bleaching occurs
under existing restorations or brackets.9 Once
the patient realized he did not have to wait until
the end of aligner treatment when the buttons
were removed to pursue bleaching, he chose to
undergo the bleaching treatment during clear
aligner treatment.
The mandibular arch was chosen for treat-
ment first, as it is recommended that bleaching
be performed one arch at a time so the patient
can better evaluate the difference between the
treated and untreated arches.10 In this case, the
patient was more concerned about the esthet-
ics in the mandibular arch than the maxillary
arch, thus the decision was made to initiate
treatment on the mandibular arch. The patient’s
clear aligner trays were evaluated for fit in the
mouth (Figure 1). A 10% carbamide peroxide
bleaching material was dispensed, and the pa-
tient was instructed to apply one drop of the
bleaching material per tooth in the tray every
night and to wear the tray overnight. Although
the patient had slight modeling of his teeth, the
initial shade of the middle third of the man-
dibular teeth taken with a shade guide prior to
initializing bleaching was A3.
After a month of nightly bleaching the pa-
tient was re-evaluated, and the mandibular teeth
were deemed A1, with an obvious difference
in color apparent between the maxillary and
mandibular teeth (Figure 2). This change in
color demonstrated that the trays can be used for
vital bleaching (Figure 3).
Next, the removal of the composite buttons
after treatment would determine if the bleach-
ing method can be considered completely suc-
cessful and a valid treatment modality or if fur-
ther bleaching would be required to remove any
yellowish unbleached area under the button. A
day after the 1-month bleaching photographs

1 2

3 4
Fig 1. Case 1. Patient before bleaching with clear aligner trays in place. Fig 2. Patient after bleaching man-
dibular arch nightly for 1 month with clear aligner trays in place, demonstrating the efficacy and safety of
bleaching during aligner treatment. Fig 3. After bleaching, but with the composite buttons still in place, a
color change was demonstrated. Fig 4. Patient after bleaching of mandibular arch and removal of com-
posite buttons; there was no remaining unbleached area in the button location of tooth No. 21.

4 CDEWorld EBOOK SERIES June 2024 | Volume 12 Number 233 www.cdeworld.com

 CONTINUING EDUCATION TEETH BLEACHING DURING CLEAR ALIGNER TREATMENT

5 6

7 8
Fig 5. Case 2. Patient prior to clear aligner therapy who was also interested in bleaching. Fig 6. Pre-
bleaching shade of the maxillary left canine with a composite button. Fig 7. Pre-bleaching shade of the
maxillary right canine with a composite button. Fig 8. Post-bleaching shade prior to removal of compos-
ite buttons.

were taken, the orthodontist removed the but-
tons. As shown in a photograph taken imme-
diately after button removal (Figure 4), no
noticeable yellowish unbleached area was pres-
ent on the facial surface of tooth No. 21 where
the composite button had been bonded.
Case 2
A 23-year-old female patient undergoing clear
aligner treatment presented with composite but-
tons on teeth Nos. 4 through 7, 11 through 13,
20, 22, and 28 and was interested in bleach-
ing to lighten the shade of her teeth. The only
medications she was taking were for birth con-
trol on a regular basis and allergy symptoms
(loratadine) only as needed. Her medical and
dental histories were noncontributory.
Like the previous patient, this patient was un-
aware that teeth bleaching could be performed
simultaneous to orthodontic treatment using the
existing aligner trays, and she expected to be
able to do the bleaching only when the ortho-
dontic treatment was completed. However,
once the patient realized she had the choice
of undergoing bleaching treatment concurrent
with her clear aligner therapy rather than wait
until after its completion, she opted to do so.
In this case, the patient chose to begin treat-
ment on the maxillary arch because in her esti-
mation it was the more unappealing of the two
arches esthetically. The patient’s pre-bleaching
shade photographs were taken (Figure 5) and
aligner trays were evaluated for fit in the mouth.
A 10% carbamide peroxide bleaching material
was dispensed, and the patient was instructed
to apply one drop of the bleaching material
per tooth in the tray every night and to wear
the tray overnight. The shade of the maxillary
teeth was taken in the middle third of the teeth
using a shade guide. The shade was A2 for the

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 CONTINUING EDUCATION
9 the tooth under porcelain veneers by bleaching
10
Fig 9 and Fig 10. Post-bleaching shade of the
maxillary right (Fig 9) and left (Fig 10) canines
taken 1 week after removal of the composite but-
tons demonstrated bleaching occurred under the
buttons and throughout each tooth.
canines (almost A3 at the gingival) and B1 for
the incisors (Figure 6 and Figure 7).
The patient was re-evaluated after 1.5 months
of nightly bleaching (Figure 8); the maxillary
incisors were still B1, and the canines were
closer to A1. This change again demonstrated
that the aligner trays can be used successfully
for vital bleaching. Then, after almost 2 months
of bleaching, the buttons were removed by the
orthodontist, and photographs were taken im-
mediately and 1 week later. No noticeable yel-
lowish unbleached blemishes were apparent on
the facial surfaces of teeth Nos. 6 or 11 where
the composite buttons had been bonded (Fig-
ure 9 and Figure 10).
Discussion
The vital tooth tray bleaching procedure devel-
oped by Haywood and Heymann in 1989 has
6 CDEWorld EBOOK SERIES June 2024 | Volume 12 Number 233
TEETH BLEACHING DURING CLEAR ALIGNER TREATMENT
been shown to change the color of both enamel
and dentin.11 The carbamide peroxide molecule
is small enough to penetrate through the enamel
interprismal spaces and dentin in 5 to 15 min-
utes.9 This effective penetration changes the
color of the underlying dentin and therefore
the color of the actual tooth. It similarly has
also been demonstrated to change the color of
from the lingual.12
Early research has indicated that just as a por-
tion of the tooth cannot be “spot bleached” due
to the permeability of the tooth and the capil-
lary action of the peroxide, a spot or area on
the tooth conversely cannot be isolated from
the bleaching process.13 With the method of
bleaching in the vital tooth tray bleaching pro-
cedure, the carbamide peroxide would reach
the dentin subjacent to the composite button
used in the clear aligner system as well as the
surrounding dentin. This phenomenon causes
the color of the tooth to change throughout the
entire tooth and surface and not just where the
bleach comes into actual direct contact. There-
fore, upon removal of the composite button it
can be expected that a thoroughly bleached
tooth will result without yellowish unbleached
areas under the composite button area. If there
were to be any yellow areas, they would most
likely be residual composite from the bonding
procedure, which embeds into the tooth at least
25 microns because of the acid-etch step in the
bonding procedure.14 Abrasion techniques are
used after debonding orthodontic brackets to
remove this composite.
Based on this information, the authors have
presented a technique that enables bleaching
concurrent with clear aligner orthodontic treat-
ment. This method can save on material usage
and time because of streamlined procedures.
The patient uses an already-existing tray and
can undergo the bleaching process during ortho-
dontic treatment rather than waiting until it is
completed. Additionally, bleaching tray fabri-
cation is eliminated.
www.cdeworld.com
 CONTINUING EDUCATION
Upon removal of the composite button it can be expected that
a thoroughly bleached tooth will result without yellowish
unbleached areas under the composite button area
Because the composite button must be re-
tained to ensure the correct placement of the
orthodontic tray, it is reasonable to question
what effect the carbamide peroxide might have
on the bond of this attachment and its potential
to debond. The carbamide peroxide bleaching
material has been shown to actually strengthen
the composite bond in a chemically cured com-
posite and have no effect on a light-cured com-
posite.15 Generally, composite cures only about
70%, so the additional carbamide peroxide fur-
ther increases the bond strength of the brack-
ets by supplying oxygen.The opposite of this is
true if bleaching is performed immediately pri-
or to bonding. In that case, the residual oxygen
in the tooth from bleaching reduces the bond
strengths by 25% to 50%.16 Patients should
wait at least 2 weeks after bleaching before any
bonding procedure is attempted to allow the
complete dissipation of the oxygen from the
enamel.10 However, once the composite mate-
rial has been polymerized, then bleaching over
the bonded composite will either further polym-
erize the composite or leave it unaffected. For
this reason, the dentist will have to coordinate
the timing of the bleaching application and the
tray sequencing if additional composite bonded
buttons are needed during treatment.
Sensitivity may often occur during tradition-
al orthodontic treatment as well as clear align-
er treatment.17 Bleaching trays have proven
to be a useful delivery method for potassium
nitrate-fluoride for sensitivity treatment.8,18,19
The sensitivity could be a result of the orthodon-
tic movement or the bleaching process. In ei-
ther case, a 10- to 30-minute application of 5%
7 CDEWorld EBOOK SERIES June 2024 | Volume 12 Number 233
TEETH BLEACHING DURING CLEAR ALIGNER TREATMENT
potassium nitrate, either from a professional-
ly supplied product or by using a desensitiz-
ing toothpaste in the tray, can reduce or elimi-
nate sensitivity in more than 90% of patients.10
Hence, the availability of the clear aligner trays
provides an effective method to address any
sensitivity during treatment.
Additional benefits of using 10% carbamide
peroxide in the clear aligner tray may be im-
proved oral hygiene and reduction of caries.
All bleaching studies of 10% carbamide per-
oxide have shown an improvement in gingival
indices during treatment.6 It has been reported
that orthodontic patients who wear a traditional
bleaching tray over traditional braces to apply
10% carbamide peroxide during orthodontic
treatment may experience a caries control bene-
fit in addition to tooth whitening.6 A challenge
of this caries control treatment was the cost of
fabricating custom-fitted bleaching trays ev-
ery few months to fit over the braces due to
teeth movement from the orthodontic treatment.
One solution to this challenge has been the use
of custom-fitted “boil and form” trays made
directly in the mouth over the braces that do
not require an alginate impression or vacuum-
formed matrix system. While removable clear
aligner therapy simplifies hygiene considerably
compared to traditional orthodontic brackets
and bands, the ability of the bleaching mate-
rial to help control caries is an added benefit.
Conclusions
Two case reports demonstrated that a clear
aligner tray can be used as a successful bleach-
ing tray during aligner therapy and that the
www.cdeworld.com
 CONTINUING EDUCATION
bleaching is effective in changing teeth color
without leaving a yellowish unbleached por-
tion of the tooth where the composite button
was bonded. The concern that bleaching while
the composite button is on the tooth will leave
a discolored portion of the tooth is unwarrant-
ed. When performed during clear aligner treat-
ment, this approach offers patients a more time-
efficient and less costly option for bleaching
and can potentially treat sensitivity, impact gin-
gival health, and reduce caries.
ABOUT THE AUTHORS
Rhoda J. Sword, DMD
Associate Professor, Department of Restorative Sciences,
Augusta University, Augusta, Georgia
Van B. Haywood, DMD
Professor, Department of Restorative Sciences, Augusta
University, Augusta, Georgia
Queries to the author regarding this course may be submitted
to authorqueries@broadcastmed.com.
REFERENCES
1. Vlaskalic V, Boyd R. Orthodontic treatment of a
mildly crowded malocclusion using the Invisalign
System. Aust Orthod J. 2001;17(1):41-46.
2. Levrini L, Mangano A, Montanari P, et al. Perio-
dontal health status in patients treated with the
Invisalign® system and fixed orthodontic appliances:
a 3 months clinical and microbiological evaluation.
Eur J Dent. 2015;9(3):404-410.
3. Haywood VB, Leonard RH Jr, Nelson CF. Efficacy
of foam liner in 10% carbamide peroxide bleaching
technique. Quintessence Int. 1993;24(9):663-666.
4. Javaheri DS, Janis JN. The efficacy of reservoirs in
bleaching trays. Oper Dent. 2000;25(3):149-151.
5. Miller MB, Castellanos IR, Rieger MS. Efficacy
of home bleaching systems with and without
tray reservoirs. Pract Periodontics Aesthet Dent.
2000;12(6):611-614.
8 CDEWorld EBOOK SERIES June 2024 | Volume 12 Number 233
TEETH BLEACHING DURING CLEAR ALIGNER TREATMENT
6. Lazarchik DA, Haywood VB. Use of tray-applied
10 percent carbamide peroxide gels for improving
oral health in patients with special-care needs. J Am
Dent Assoc. 2010;141(6):639-646.
7. Seleem D, Lazarchik D, Dadjoo S, et al. Effect of
10% carbamide peroxide on tooth shade, plaque
index, and gingival index during Invisalign treatment
[abstract]. J Dent Res. 2020;99(spec iss A):
Abstract 1587.
8. Curtis JW, Dickinson GL, Downey MC, et al. Assess-
ing the effects of 10 percent carbamide peroxide on
oral soft tissues. J Am Dent Assoc. 1996;127(8):
1218-1223.
9. Cooper JS, Bokmeyer TJ, Bowles WH. Penetration
of the pulp chamber by carbamide peroxide bleach-
ing agents. J Endod. 1992;18(7):315-317.
10. Haywood VB. The “bottom line” on bleaching
2008. Inside Dentistry. 2008;4(2):82-89.
11. McCaslin AJ, Haywood VB, Potter BJ, et al.
Assessing dentin color changes from nightguard vital
bleaching. J Am Dent Assoc. 1999;130(10):1485-1490.
12. Haywood VB, Parker MH. Nightguard vital
bleaching beneath existing porcelain veneers: a
case report. Quintessence Int. 1999;30(11):743-747.
13. Bowles WH, Ugwuneri Z. Pulp chamber penetra-
tion by hydrogen peroxide following vital bleaching
procedures. J Endod. 1987;13(8):375-377.
14. Swift EJ Jr, Perdigão J, Heymann HO. Bonding to
enamel and dentin: a brief history and state of the
art, 1995. Quintessence Int. 1995;26(2):95-110.
15. Tanner J, Smith B, Rueggerberg F, Haywood
V. Effect of dentist-prescribed home bleaching on
orthodontic bracket retention. J Dent Res. 2001;80
(1 suppl):205.
16. Lai SC, Tay FR, Cheung GS, et al. Reversal of
compromised bonding in bleached enamel. J Dent
Res. 2002;81(7):477-481.
17. Polat Ö. Pain and discomfort after orthodontic
appointments. Semin Orthod. 2007;13(4):292-300.
18. Haywood VB, Caughman WF, Frazier KB, My-
ers ML. Tray delivery of potassium nitrate-fluoride
to reduce bleaching sensitivity. Quintessence Int.
2001;32(2):105-109.
19. Curtis JW Jr, Dickinson GL, Myers ML, Russell CM.
Evaluating the effects of a dentist-supervised,
patient-applied carbamide peroxide bleaching agent
on oral soft tissues. J Esthet Dent. 1995;7(1):18-25.
www.cdeworld.com
 CONTINUING EDUCATION QUIZ
Teeth Bleaching Efficacy During Clear Aligner
Orthodontic Treatment
Rhoda J. Sword, DMD; and Van B. Haywood, DMD
TO TAKE THE QUIZ, VISIT: CDEWORLD.COM/EBOOKS/CE/233
1. With the clear aligner technique, composite
attachments, or buttons, are:
A. bonded to all teeth to aid in the retention of the
orthodontic tray.
B. bonded to several teeth to aid in the retention of C. the potential for white spot lesions.
the orthodontic tray.
C. bonded to one or at most two teeth to aid in the
retention of the orthodontic tray.
D. not bonded to any teeth, as they are not necessary
for the retention of the orthodontic trays, which are
self-retaining.
2. The composite attachments on the teeth can
compromise what due to their irregular shapes
protruding from the teeth?
A. The fit of the clear aligner tray
B. The bleaching process
C. Oral hygiene
D. The retention of the clear aligner tray
3. For patients undergoing clear aligner treatment, use
of their existing tray as the delivery mechanism for
bleaching material can:
A. be costly, because some alternative methods such
as swabs or whitening strips are less expensive.
B. be inefficient, because whitening trays are less
effective than other bleaching methods.
C. interfere with tooth movement
D. be highly cost-effective, because separate the tray.
impressions and trays would not have to be made
for a patient interested in bleaching.
4. Although some advocates of bleaching encourage the
use of scalloped trays with reservoirs for the
bleaching material, studies have shown that bleaching
with non-scalloped, non-reservoir trays using 10%
carbamide peroxide bleaching material is:
A. just as safe and can also conserve bleaching material.
B. superior to scalloped trays.
C. more frequently used, despite its inferior safety.
D. endorsed by more dental health professionals who
are advocates of bleaching.
5. Bleaching during clear aligner treatment can improve:
A. brushing and flossing.
B. oral hygiene.
C. correction of malignment.
D. None of the above
Course is valid from 6/1/2024 to 6/30/2027. Participants must
attain a score of 70% on each quiz to receive credit. Participants
receiving a failing grade on any exam will be notified and per-
mitted to take one re-examination. Participants will receive an
annual report documenting their accumulated credits, and are
urged to contact their own state registry boards for special CE
requirements.
9 CDEWorld EBOOK SERIES June 2024 | Volume 12 Number 233
2 Hours CE Credit
6. Bleaching during clear aligner treatment can further
minimize:
A. tray wear times.
B. patient compliance.
D. All of the above
7. One possible concern among patients bleaching
during clear aligner treatment is the potential for lack
of color change on:
A. the teeth not covered by the tray.
B. the distal portion of the teeth.
C. the buccal portion of the teeth.
D. the portion of the tooth covered by the composite
attachment.
8. Research has shown that peroxide penetrates
completely through enamel and dentin, and
bleaching occurs:
A. only at the level of the enamel.
B. only on the portions of the tooth not covered by
composite attachments.
C. under existing restorations or brackets.
D. None of the above
9. In Case 1, a 10% carbamide peroxide bleaching material
was dispensed, and the patient was instructed to apply:
A. the whitening gel in a thick, even coating across
B. one drop of the bleaching material per tooth in the
tray every night and to wear the tray overnight.
C. a premeasured application of the gel across the
tray, and to wear the tray throughout the day.
D. None of the above
10. In Case 1, the initial shade of the middle third of the
patient’s mandibular teeth was A3. After a month of
nightly bleaching, the mandibular teeth were deemed
A1. This change in color demonstrated:
A. that the trays can be used for vital bleaching.
B. that the mandibular teeth are easier to bleach with
aligner trays than the maxillary teeth.
C. that a shade change of no greater than two shades
can be expected.
D. All of the above
PEER-REVIEWED
AEGIS Publications, LLC, is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identify-
ing quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of
credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at https://www.ada.org/cerp/.
AEGIS Publications, LLC, is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of
this program provider are accepted by the AGD for Fellowship/Mastership and membership maintenance credit. Approval does not imply acceptance by a state or
provincial board of dentistry or AGD endorsement. The current term of approval extends from 1/1/23 to 12/31/28. Provider ID# 209722.
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 CASE REPORT
Anterior Intrusion With
Clear Aligners
Andrew Ferris, DDS, MS
D
eep bites, which are very com-
monly seen in practice, can de-
velop for a number of reasons,
but oftentimes, patients present
with a lack of coupling due to a
class II dental or skeletal malocclusion. This
can result in supereruption of the anterior teeth
and create challenging situations for clinicians.
Research shows that deep bites can cause path-
way interferences due to a restriction in the en-
velope of function, which can lead to acceler-
ated attrition. Deep bites can also increase the
load on the temporomandibular joints and af-
fect overall function. Although there are sev-
eral treatment options that can be presented to
these patients, including traditional orthodon-
tics, clear aligners can be an effective appli-
ance to correct this type of malocclusion when
correctly designed.
Case Report
A 57-year-old female patient presented to the
office with severe malocclusion. She had a
deep bite of greater than 100% that was im-
pinging on the palate as well as severe crowd-
ing in her anterior mandible. In addition, she
had a multitude of other health conditions, in-
cluding severe intraoral scarring due to pri-
or ingestion of a caustic substance. An initial
cone-beam computed tomography (CBCT)
scan was acquired during the examination.
Developing an orthodontic treatment plan
was challenging due to the patient’s severe
amount of mandibular crowding and severe
two-plane occlusion. It would have been easy
to justify premolar extractions; however, she
was brachyfacial, and this approach would
10 CDEWorld EBOOK SERIES June 2024 | Volume 12 Number 233
ANTERIOR INTRUSION WITH CLEAR ALIGNERS
ABOUT THE AUTHOR
Andrew Ferris, DDS, MS
Lecturer, Orthodontics
Loma Linda University
School of Dentistry
Loma Linda, California
Private Practice
Santa Barbara, California
have compromised her function and the appear-
ance of her profile. Furthermore, the use of tra-
ditional fixed appliances would have been very
challenging in this situation due to the severe
two-plane occlusion and crowding. The path of
least resistance would be in the anterior direc-
tion, which could result in severe proclination
and compromise the incisors. Therefore, clear
aligner treatment was used to fully intrude the
lower anterior teeth while developing the arch
forms in order to create space to align the teeth
and finish with a healthy functional occlusion.
The treatment was enhanced by daily use of a
device that delivers micropulsed vibrations to
accelerate tooth movement.
During treatment, the patient decided to pur-
chase a low-level laser therapy device online
and switch aligners every 5 days to further ac-
celerate the treatment. Although this was not
recommended, within less than 6 months, her
lower anterior teeth had intruded approximately
6.6 mm. This shows how powerful clear align-
ers can be as a tool, even in treating the most
complex cases.
The final result of intruding the lower incisors
was a level occlusal plane. A final CBCT scan
was acquired and compared with the initial
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 CASE REPORT ANTERIOR INTRUSION WITH CLEAR ALIGNERS

CBCT scan, and measurements were made
from the incisal edges of the mandibular ante-
rior teeth to the border of the mandible and from
the occlusal surfaces of the premolars to the
border of the mandible. After 50 weeks of treat-
ment, the mandibular incisors had been intrud-
ed by approximately 8 mm with insignificant
extrusion of the posterior teeth. As a part of the
treatment, teeth Nos. 24 and 25 were differen-
tially intruded in order to create the space neces-
sary to restore the exposed dentin, and a lingual
wire was placed in the anterior mandible for re-
tention. The patient continued to follow-up over
the next 5 years to ensure stability.

1 2 3

4 5 6

7 8 9
Fig 1. Pretreatment full-face patient portrait. Fig 2. Pretreatment full-face patient smile portrait.
Fig 3. Pretreatment panoramic radiograph showing the two-plane occlusion. Fig 4 and Fig 5. Pretreatment
right profile patient portrait (Fig 4) and pretreatment cephalometric radiograph (Fig 5) showing lack of
lower lip support and class II dental and skeletal relationship. Fig 6. Pretreatment retracted photograph
showing the severe deep bite. Fig 7 and Fig 8. Pretreatment retracted right and left lateral photographs
showing the amount of overbite and overjet. Fig 9. Pretreatment retracted photograph with the teeth apart
showing the severe two-plane occlusion.

11 CDEWorld EBOOK SERIES June 2024 | Volume 12 Number 233 www.cdeworld.com

 CASE REPORT ANTERIOR INTRUSION WITH CLEAR ALIGNERS

10 11 12

13 14 15

16 17 18 19

20 21 22 23 24
Fig 10 and Fig 11. Pretreatment upper and lower occlusal view photographs showing the severe level of
crowding, especially in the lower anterior region. Fig 12. Progress photograph acquired after 6.5 months
of clear aligner treatment demonstrating that the lower anterior teeth had been intruded by approxi-
mately 6.6 mm. Fig 13. Posttreatment retracted photograph. Fig 14. Posttreatment retracted photo-
graph with the teeth apart showing the leveling of the occlusal plane and differential intrusion of teeth
Nos. 24 and 25 in preparation for restoration to cover exposed dentin. Fig 15 and Fig 16. Posttreatment
right and left lateral photographs. Note that the left lateral view shows less than complete correction,
but the patient expressed that she was happy with the result. Fig 17 and Fig 18. Posttreatment upper
and lower occlusal view photographs. Note the lingual wire that was placed in the lower anterior region
for retention. Fig 19. Posttreatment panoramic radiograph demonstrating that the lower anterior teeth
were intruded by approximately 8 mm. Note the slight root blunting of the lower anterior teeth that
occurred as a result of their intrusion. Fig 20. Posttreatment cephalometric radiograph showing in-
creased proclination of the lower anterior teeth. Fig 21. Posttreatment right profile patient portrait.
Fig 22. Posttreatment right oblique patient portrait. Fig 23. Posttreatment full-face patient portrait.
Fig 24. Posttreatment full-face patient smile portrait.

12 CDEWorld EBOOK SERIES June 2024 | Volume 12 Number 233 www.cdeworld.com

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