This case report is based on the clear aligner treatment of an adult patient who presented with moderate crowding and an unpleasant smile. Crowding was treated with arch expansion and interproximal reduction. A total of 28 sets of clear aligners were delivered, with a wear time of 22 hours per day for 10 days. The treatment duration was 10 months. Thus, the case study underscores the reliability of orthodontic treatment with clear aligners for addressing moderate crowding. The discreet nature of these aligners not only enhances periodontal health but also increases patient acceptance.
Clear aligners have demonstrated their versatility in addressing a range of malocclusions, including crowding, spacing issues, and teeth that are out of alignment. At the inception of clear aligners in orthodontics, their primary purpose was to address mild crowding. However, as materials and computer-aided tooth movement design have advanced, the scope of clear aligner applications has expanded to encompass moderate to severe crowding, whether they involve extraction or non-extraction approaches [1]. They can also be effectively utilized in cases involving open bite corrections and class III malocclusions [2]. Nevertheless, the effectiveness of aligners can vary depending on the complexity of the case and the specific tooth movements required. It's worth noting that the forces exerted by aligners are comparable to those produced by traditional fixed appliances [3,4].
Clear aligners can effectively address crowding issues through various methods, including proclining teeth, arch expansion, interproximal reduction (IPR), and, in severe cases, extraction, much like the techniques employed in traditional orthodontic treatments [5,6]. Nevertheless, it's important to note that in extraction cases, achieving pure translation movements with aligners may be less predictable when compared to other orthodontic approaches [7].
This case report is focused on utilizing clear aligner treatment to rectify a condition of moderate crowding in the patient's dentition. It aims to document the process, progress, and outcomes of this specific orthodontic treatment in addressing the crowding issue. The report will likely include details about the treatment plan, the application of clear aligners, the patient's response to the treatment, any challenges encountered, and ultimately, the success achieved in resolving the crowding problem. This information can serve as a valuable reference for other practitioners and patients considering similar treatment for moderate crowding issues.
A 29-year-old healthy male sought our dental services with concerns regarding tooth crowding and an unsightly smile. The patient's medical history was largely uneventful, except for a prior unsuccessful attempt at orthodontic treatment, which involved the extraction of a lower incisor. During the extraoral examination, we noted that the patient had a well-proportioned face, an orthognathic profile, competent lips, and an acute nasolabial angle. There were no reported symptoms or alterations related to the temporomandibular joint.
Upon smile analysis, we found that there was an adequate display of incisors, but the alignment of the teeth was suboptimal. Intraoral examination of the patient revealed Class I relationships for both molars and canines. The overjet (horizontal overlap of the upper and lower teeth) was excessive, while the overbite (vertical overlap of the upper and lower teeth) was within acceptable limits. Notably, the midline of the maxillary teeth deviated 1mm to the left of the patient's facial midline.
Intraorally, the patient exhibited moderate crowding in both the upper and lower dental arches, with 5mm of crowding in the maxilla and 6mm in the mandible. A panoramic radiograph confirmed that the patient had a healthy periodontal condition with no signs of cavities, root resorption, or any dental or pathological abnormalities. Additionally, cephalometric analysis revealed a skeletal Class I relationship and a normodivergent facial pattern.
Treatment Objectives
The primary goal of the orthodontic treatment was to address crowding concerns through the use of clear aligners. Secondary goals included the establishment of a healthy, functional, and lasting occlusion, as well as the enhancement of dental aesthetics.
Treatment Options
We discussed various treatment choices with the patient, which included:
- The initial option involved traditional braces for orthodontic treatment. However, the patient declined this option due to their preference for a more aesthetic appliance.
- The second option was to use clear aligners, aligning with the patient's desire for a more esthetic solution.
Treatment procedure
Taking into account the patient's youthful age of 29 and his dynamic involvement as a speaker and active member of the social community, he preferred the clear aligner system. Consequently, we proceeded to gather intraoral and extraoral photographs, PVS impressions, panoramic X-rays, and lateral cephalometric records. These collected records were transmitted to the OrthoPath facility for the formulation of a customised treatment plan.
The panoramic X-ray affirmed the presence of ample bone structure and showcased excellent oral hygiene, thereby meeting the essential criteria for orthodontic treatment. No further dental procedures were required, rendering the case suitable for the continuation of clear aligner treatment.
After submitting the records, a 3D treatment plan was generated. This plan involved 28 stages of treatment, including arch expansion and interproximal reduction (IPR) for both the upper and lower arches. A treatment simulation was presented to the patient for review, and upon their satisfaction, approval was granted.
The treatment plan was received and discussed with the patient within 10 days of the data submission. The patient expressed high levels of satisfaction with the proposed treatment plan, and no modifications were deemed necessary. A total treatment duration of 1 year and 2 months was recommended to the patient, which they readily approved. Consequently, treatment commenced shortly thereafter.
Interproximal reduction is the technique of carefully removing the thin enamel layer interproximally between the neighbouring teeth to unravel crowding [8]. There are different methods of IPR, including burs, discs, and abrasive strips [9]. In this study, IPR was achieved using a thin diamond-coated double-sided abrasive strip. It was measured using an IPR gauge, followed by the application of topical fluoride to avoid any adverse effects.
Treatment Progress
Treatment commenced in January 2020. Within two weeks, we received the IPR and MRF forms from the aligner facility, along with 28 sets of upper and lower aligners. The recommended wear time for each set was 22 hours per day for ten days. The patient received comprehensive guidance on oral hygiene and periodontal health. Initially, the patient was provided with the first set of aligners and was scheduled for an IPR appointment before starting the second set. We performed an IPR procedure, reducing 0.6mm between the upper laterals and canines bilaterally and 0.7mm between the upper canines and first premolars bilaterally.
Subsequently, the patient received the next sets of aligners and was evaluated for periodontal health and aligner tracking every three months, with satisfactory results. An IPR visit was scheduled again after aligner 23, during which 0.6mm of enamel was removed between the upper left central and lateral incisors before providing the next batch of aligners. The patient demonstrated good compliance, and the treatment was successfully completed.
Following the treatment, two sets of retainers were issued. The patient was instructed to wear them full-time for the first six months, followed by night-time wear for three months, and then alternate-night-time wear for the remaining three months.
Treatment Result
The entire treatment course spanned a period of 10 months, with each aligner being worn for a substantial 22 hours per day and replaced every 10 days. By the conclusion of this treatment, the initial crowding issues were successfully addressed, leading to the establishment of Class I molar and canine relationships. The result was the achievement of an ideal overjet and overbite, ensuring proper alignment and bite function.
Furthermore, the treatment concluded with the harmonious centering of the maxillary and mandibular midlines, enhancing both the esthetic and functional aspects of the patient's smile. Importantly, the periodontal health was carefully maintained throughout the treatment, with no evidence of gum recession or the formation of periodontal pockets, ensuring the overall well-being of the patient's oral health.
The aim of this study was to evaluate the reliability of resolving crowding issues, the effectiveness of various space-gaining techniques, and their interrelationships in order to establish a dependable protocol for achieving predictable outcomes.
In this specific case involving moderate crowding, clear aligners were successfully employed over a duration of 10 months. Crowding was alleviated through a combination of arch expansion and interproximal reduction. A total of 28 sets of aligners were provided for both the upper and lower arches. While alternative treatment options were presented to the patient, they opted for clear aligners due to their discreet, hygienic, and comfortable nature. Clear aligners represent a unique treatment approach for adult orthodontic patients, addressing aesthetic, hygiene, and metal allergy concerns while offering a treatment duration comparable to traditional fixed appliances [10].
In clear aligner treatment, patient compliance is of paramount importance. Patient education can serve as a motivational tool, influencing patient acceptance of the appliance and improving compliance [11]. In this case, the patient's active involvement and interaction with their orthodontist significantly contributed to the treatment's success. The patient was engaged with the ClinCheck software, which visually demonstrated the anticipated tooth movement and progress throughout the treatment. This underscores the value of ClinCheck as an educational tool to illustrate the final treatment objectives to the patient.
However, it is worth noting that the clear aligner system does have certain limitations. It may be less predictable in cases involving severe derotations, complex extrusions, or significant translations, which might necessitate additional treatment modalities [12]. Despite potentially higher laboratory fees compared to conventional appliances, the virtual treatment setup, ease of use, and high patient acceptance can often offset the additional cost. This setup not only aids in diagnosis but also serves as an educational tool for patients. Furthermore, patient cooperation is crucial for the overall success of the treatment, which, in this case, was excellent due to the patient's enthusiasm for the process.
In summary, this case study underscores the reliability of orthodontic treatment with clear aligners for addressing moderate crowding. The discreet nature of these aligners not only enhances periodontal health but also increases patient acceptance. Moreover, the precise control of orthodontic movements with minimal risk of losing anchorage makes it a compelling option for clinicians when managing moderate crowding cases.
A written consent form was signed by the patient for the use of the dental records for publications and social media marketing. Also, there is no conflict of interest with this paper.
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