Orthodontic Continuing Education

VWP Christian Groth Case ID J9G3TS TxD Two clear teeth aligners rest against a grey background beside text. A bright red 3M logo is in the upper left corner. Onscreen text: 3M Clarity� Esthetic Orthodontic Solutions Correction of Moderate Crowding 3M� Clarity� Aligners Flex + Force PRESENTER: Hello, today we are going to discuss a case of moderate crowding treated with the 3M Clarity Aligners new force and flex system. The next slide shows a side-by-side models of the patient�s teeth before and after alignment above a numbered timeline of the treatment plan. The realigned model has grey nibs on the surface of several teeth. To the left side there is text. Along the bottom of the slide is a copyright notice and a 3M logo, which remain for the duration of the video. Onscreen text: Age: 56 years and 10 months Chief Concern: Anterior crowding on both arches. Case Diagnostics: - Class I - Well balanced facial profile - Moderate crowding - Normal overbite and overjet - Thin periodontal biotype with mild recession on lower anterior Treatment Objectives: Non-extraction with IPR for crowding and black triangle along with mild arch expansion. Maintain occlusion and idealize alignment. Further recession is possible which may require a soft tissue graft post-treatment. Wear Interval: Weekly Treatment Length: Treatment is estimated at 16 months and we are in month 4 Treatment Design Aligners: 53 planned Clarity Flex: Stages 1-42 Clarity Force: Stages 43-53 13| �3M 2021. All Rights Reserved. 3M Clarity� Esthetic Orthodontic Solutions PRESENTER: Today's case is a 56 year old male with the chief concern of crowding in both arches in the anterior. This case is planned for 53 total stages. And the first 42 stages are the flex aligners, which is the more flexible material, with the last 10 stages, stage 43 through 53, being the force material, a little stronger material that is used for case finishing in this case. Rhe interval is weekly changes, but all patients have the ability to change at a slower interval if necessary, if they're seeing that things are not tracking or feel that they did not get the number of hours required in any particular tray. This case is estimated to be approximately 16 months and we are at the current moment four months into the case. We will go over the diagnostics and treatment objectives as we go through the records. The next slide shows three photos of an older white male. In the first two photos he is facing forward, first with a wide grimace, then a neutral expression. In the third photo, he is in profile with a neutral expression. Onscreen text: Initial Photos PRESENTER: So as you can see, this patient has a well-balanced facial profile. Anterior aesthetics are adequate with no plans on changing either the anterior or posterior occlusal plane. The next slide shows three close-up frontal photos of the patient�s teeth. The first are right-side up with the patient�s teeth first clenched together, then slightly opened. The third is upside-down angled toward the bottom teeth, accentuating the crowding of his front two teeth, which overlap one another. PRESENTER: Dentally, the patient has a normal overbite and overjet. He does have class one occlusion both right and left hand side. Lower midline is deviated slightly to the left, upper midline is deviated slightly to the right. Of note is the relatively thin periodontal biotype with a little bit of recession starting on, especially, lower left one. This has been discussed with the patient and he is aware that there is a potential for progression of the recession which would require a soft tissue graft post-treatment. Looking at the case diagnostics and the treatment goals, we ran through several simulations to determine whether we wanted to treat this with extraction, or to treat this as a non-extraction case. And the decision was made to treat this as non-extraction using both mild arch expansion and interproximal reduction in order to gain the space necessary for alignment and also to control the black triangles that are anticipated to show up during the treatment process. The next slide shows top-down photos of the top and bottom rows of teeth. The top row has several fillings and a gold cap on a back molar. The bottom teeth have several metal fillings and a wire wrapping around the back molars. PRESENTER: Both arches show moderate crowding in the anterior, the overlap of the centrals is anticipated to result in a black triangle and the lower crowding as well with the triangular shape of the lower incisors would- we anticipate this to show black triangles. One of the things that we will be doing our best to control is the anterior posterior position of the lower incisors, in order to make sure that we do not cause any further recession to as much as our ability allows. The next slide shows left and right side-views of the patient�s teeth. PRESENTER: And the buccal segments show a really nice locked in class one occlusion. So, our goal is definitely to maintain that. The next slide shows x-ray photos of the patient�s teeth from frontal and profile views. Onscreen text: Initial PANO & Cephalometric PRESENTER: Radiographically there is nothing of note on the panoramic radiograph, and the cephalometric radiograph shows a well-balanced class one skeletal profile with normal angulation of all measurements. The view switches to a 3D model of the patient�s teeth above a timeline of the alignment trays. PRESENTER: Moving into the advanced treatment design in the oral care portal, we are showing the staging for this case. The bottom teeth disappear as the presenter rotates the model to a top-down view of the top teeth. PRESENTER: And one of the most important things for a case like this is to make sure that the teeth have adequate space to move into. Binding is one of the number one killers of teeth movement success in clear aligners. So on the upper arch, the goal here is to create small interproximal spaces before any major rotational movements are happening, especially across that upper right central incisor. You will also see the arch expanding slightly in order to help with the space creation. So as I roll through these movements, you can see that we are expanding both in the buccal segments and across the anterior before we start the rotational movements. The cursor drags through the aligner timeline, shifting the teeth in the model. The teeth spread apart slightly, and the overlapping front teeth rotate until they are parallel to each other. He resets the timeline, then repeats. PRESENTER: The switch over from flex to force happens quite late in this case. The reasoning for that is because I treat flex, the flex movements, as the movements that we accomplish in our nickel titanium wires. And one of the main movements are the leveling and aligning movements. So we're not switching over to force until the last 10 trays when we have the alignment pretty much set. And we are working on finishing movements, idealizing torque and closing spaces. The view switches to a top-down view of the bottom teeth. As the presenter moves through the timeline, the six front teeth, which all curve together, separate and straighten out. PRESENTER: In the lower arch, the objective and the way we achieve the space necessary for alignment is a little bit different, because we want to minimize as much as possible the proclination of the lower incisors due to the slight recession already present. So there was a interproximal reduction planned right from the beginning in the posterior, and we used the mesial surface of those canines to push the canines and premolars back before starting any kind of rotation. So you can see that we are distalizing and expanding over the course of the first eight trays, essentially before we start moving the lower anteriors at all. From there, we do see some advancement of the lower lateral incisors in order to start the alignment process, where we will do some interproximal reduction across the anterior in order to gain the rest of the space necessary for alignment. Using the same idea of force versus flex in the lower, we want to get to the point where alignment is essentially complete before switching over to the force aligners to finalize those last movements. He leaves the slider on the last tray of the timeline, then rotates the model to a frontal view of the teeth. The top row reappears. Several of the teeth have grey nibs on their surface. PRESENTER: Our attachment design here is for essentially two different things. Our posterior attachments are for tray retention. He rotates the model to a side view and resets the timeline, then drags it forward. PRESENTER: In order to make sure that the trays adapt well and allow us to get the movements that we are expected to get. The canine attachments are rotational attachments especially on the lower you can see that we have some pretty significant rotations that we need to resolve on those canines. He rotates to a top-down view of the bottom teeth and moves through the timeline, straightening the teeth. PRESENTER: So the bevel is to the distal here so that we have a nice pushing surface in order to rotate those canines mesial in. He rotates to a frontal view of the crowded bottom teeth, then moves through the timeline. PRESENTER: The anterior attachments are simple vertical attachments, and these are for the tip of the teeth. We may end up needing to place an attachment on lower left one. I avoided it on this the first round, because I was hoping that we could get enough plastic wrapping around that tooth that we could avoid an attachment as we rotated it and tipped it into its final position. The bottom teeth disappear and the upper teeth reappear in a frontal view. PRESENTER: For the upper, this vertical beveled attachment on this upper right central is both for rotational control and tip as we get this tooth into its final position. You can see that there is a quite a large rotation on that tooth that we need to resolve. He rotates to a top-down view of the top teeth and moves back and forth through the timeline, showing the rotation of the front tooth. PRESENTER: Let's look at the movements tab here� He rotates to a frontal view of the top teeth. A chart showing the movement of the teeth in millimeters and degrees appears at the bottom of the screen. Onscreen text: Maxillary | Mandibular UR8 UR7 UR6 UR5 UR4 UR3 UR2 UR1 UL1 UL2 UL3 UL4 UL5 UL6 UL7 UL8 Extrusion/Intrusion (mm) Bucco-Lingual Translation (mm) Mesio-Distal Translation (mm) Rotation (�) Mesio-Distal Angulation (�) Bucco-Lingual Inclination (�) PRESENTER: And looking at upper right one and the reason for this attachment design, because most of us want to avoid attachments on the anterior teeth especially on the fascial of the upper incisors. You can see the upper right one has a 37-degree rotation in addition to an 18-degree tip mesial root tip on that tooth. He moves the slider back and forth. PRESENTER: And so with those two movements, we really need an attachment in order to help the predictability to make sure we get to our final result without having to take a bunch of redesign scans. He rotates to a top-down view of the top teeth at the end of the treatment, the to a side view of the top teeth. PRESENTER: In addition on the upper arch, the canines do have significant rotations of 20-degrees and almost 18-degrees. So those are rotational attachments. The premolars on the upper arch are simply for tray retention to make sure that the other movements are as predictable as possible. The bottom teeth reappear and he rotates to a frontal view. PRESENTER: At the end, our goal here is coincident midlines. He rotates the model from side to side. PRESENTER: Nice locked in posterior segments like we started with. He rotates so the view looks up at the teeth, showing the top row slightly extending over the bottom row. PRESENTER: And ideal alignment with a little bit of overjet built in because we did not want to procline the lower teeth any more than absolutely necessary. He switches to a white 3D model of the teeth with blue patches overlaying several of the teeth showing the projected movement.. Several tabs along the bottom of the screen show measurements of teeth movement. He moves the timeline to tray 15. PRESENTER: Looking at the progress scan for stage 15, we are seeing really great tracking in almost all dimensions here. The numbers at the bottom are denoting where we are in treatment and how close we are to the goal. And essentially we are looking- we hope to have as many no numbers or gray numbers as possible, with the orange and red being the numbers that we want to look at. Now it is important to understand that not all red numbers are significant. So a number like the upper right seven of 0.2 millimeters off in the buccal lingual translation movement, it does show up as red because we're not doing very much movement on that tooth. However, I don't consider a 0.2 millimeter off from the goal as being a significant thing to worry about. On the upper arch, we are seeing the buccal lingual inclination, the torque if you will, of these upper teeth. It is lagging a little bit but that is something that is expected in any kind of orthodontic treatment where we don't get as much as we plan. He rotates to a top-down view of the top row of teeth. PRESENTER: And the tracking that we see in the progress scan shows that these trays fit well enough that there is absolutely no reason to do any kind of redesign. He rotates the model to a top-down view of the bottom teeth. PRESENTER: Moving into the lower arch, we do see similar success. As far as the numbers on the bottom we don't see very many orange or red numbers. And when you look at the progress scan itself, I like to describe this as, we are looking for almost a camouflage appearance, where we have blue and white that are overlaid together. What that denotes is that there is such good tracking that there is nothing that is off so much as to see a lot of white or a lot of blue. He rotates to a front view of the bottom teeth. PRESENTER: When things are starting to not track you will see the whole tooth being blue or white, denoting that the- where the plan was and where the tooth currently is are not jiving together. The next slide shows three photos of the man mid-way through realignment. In the first he has a toothy grimace from a frontal view, in the second he has a neutral expression from a frontal view, and in the third he has a neutral expression in profile. Onscreen text: Progress Photos ( 4 months & Aligner #16) PRESENTER: Moving back to the progress records, we can see that smile aesthetics are maintained from the initial. The next photo shows side-by-side photos of the man grimacing pre-treatment and mid-treatment. PRESENTER: Tray fit has been excellent. This patient has been really very diligent about wearing these trays. And although we have some difficult movements that we are working on, you can see that the tracking is excellent thus far. Even though we are we are only in the month four of treatment. The next slide shows four close-up frontal photos of the man�s teeth. The left two are without trays and the right two are with trays on his teeth, with the crowded teeth starting to straighten. PRESENTER: Showing the trays-out and trays-in photographs shows you how well these trays are adapting. You do see a small space at the incisal of upper right two and upper left one. We did see that in the progress scan where there was a little bit of blue at the incisal edge of those teeth. That is not a reason to do a reset at this point. We are doing a great job developing the space between the upper interior and the lower interior in order to resolve the crowding. The next slide shows photos looking up at the man�s teeth that show the top front teeth extending over the bottom teeth. PRESENTER: And overjet shots again you can see the great adaptation of the trays and the space that is being formed between the upper centrals. The next slides show a side view of the man�s teeth without and with the trays, first from the right side, then from the left. PRESENTER: Looking at the buccal view, you can see that the buccal occlusion has been maintained really, really well. In a case like this where we have a significant amount of lower crowding, it's not uncommon to see posterior bite opening due to anterior interferences, and we are not seeing that happen in this case. Looking at the left hand side we're seeing the same bite relationship maintenance that we saw on the right hand side. The posterior occlusion is looking excellent. The next slide shows a top-down photo of the man�s upper teeth without and with the aligner trays. PRESENTER: Maxillary occlusal. We see the beginning of the resolution of the crowding with the space making between the upper centrals so that we can rotate upper right one mesial in. The next slide shows a top-down view of the man�s bottom teeth without and with the aligner trays. Lower, at this stage we're not going to see many changes because we are currently in the arch development and distalizing phase before we start to move the lower laterals forward. So while we do have improvement, that big improvements are going to start in the next 10 to 15 stages. The next slide has text against a grey background with graphics of four aligners flying through the air. Onscreen text: 3M Clarity� Esthetic Orthodontic Solutions Thank you! PRESENTER: Thank you very much. I hope you enjoyed this case presentation.