Treatment of a young female patient wit a combination of Invisalign and distalizing appliance. Well treated by one of our students under my supervision. Please comment

1. Treatment Completed
LK
DMD IV
Date: April 8th, 2012

3.  Age: 16 years old
 Sex: female
 C.C. “ I want my
lower 4 teeth fixed”
Pre-treatment

4.  Past medical history: NSF
 Medications: None
 Allergies: NKDA
 Past dental history: Last seen dentist
9m ago for exam and cleaning
(referred by family dentist)
 Brushes 2x/day and flosses 2x/week
 Oral hygiene: Fair (moderate plaque
and calculus accumulation

5.  Facial Type:
Normocephalic
 Facial Proprtions:
UFH = LFH
 Facial Symmetry:
Symmetrical

6.  Facial Profile:
Slightly convex
 Nasolabial angle:
Slightly obtuse
 Lips:
Upper lip length is normal
Lips normal at rest
No upper incisors showing
at rest

7.  Tongue at rest:
WNL
 Swallowing pattern:
WNL
 Muscles of mastication:
WNL
 TMJ:
Normal articulation
Normal range of motion
Normal muscles of mastication

8. Facial Symmetry
 Upper midline:
No deviation
 Upper dental midline:
No deviation
 Lower midline:
No deviation
 Lower dental midline:
Deviated 3 mm to the right
Pre-treatment

9. Right Side Dental Midline Left Side
Molar class I Upper: no deviation Molar class I
Canine class I Lower: 3mm to right Canine class I
Pre-treatment

10. 40-50 % Overbite
Pre-treatment

11. Overjet
Right: 4 mm Left: 2 mm
Pre-treatment

12.  Teeth present: 17 to 27 and 37 to 47
 Arch Shape
Upper: Lower:
Normal Normal
Pre-treatment

13.  Soft Tissue Assessment
 Fair oral hygiene
 Periodontal Status
 PSR II; moderate gingivitis
 Adequate attached gingiva
 Anterior crossbite: 1.2&4.2
 Rotations 1.3 & 4.3
Pre-treatment

14. Intra Oral Examination
 Amount of Crowding
Upper: Lower:
Moderate Mild-Moderate
Pre-treatment

15. Clinical Findings:
- All permanent dentition except for third molars are erupted
- Rotations 2.3, 3.3, 4.3
- Normal condylar and ramus architecture
Pre-treatment

16. Measurement Value Normal SD
SKELETAL
SNA 86 81º 3
SNB 80.5 78 3
ANB 5.5 3 2
Facial Angle 91.2 88 4
Witts -0.8 2 2
Mand. Plane Angle 30 33 3
Y axis 62 60 4
DENTO-ALVEOLAR
Upper inc. to NA 18 23 6
Lower inc. to NB 27 27.5 5
Upper inc./Lower 129.4 130 7
inc
Lower Inc. to 98 91.4 4
Mand. Plane
Pre-treatment

17.  Normal Curve of Spee For Maxilla
 Moderate Curve of Spee for Mandible
Pre-treatment

18. Molar rotation: 16, 26, 36, 46 - normal
Angle Classification:
Right: Class I molar, Class I canine
Left: Class I molar, Class I canine
Overbite 40-50 %
Overjet 4 mm (right), 2 mm (left)
Pre-treatment

19.  Abnormal tip: 11 & 12(mesial), 21&22 (mesial)
 Abnormal torque:
Labial: 22, 42
Lingual: 12, 11, 21, 32 ,31 ,41, 43
 Rotation:
11 mesial, 12 mesial, 21 mesial, 22 mesial, 32 distal, 33
distal, 35 mesial, 36 mesial, 43 distal, 45 mesial
Pre-treatment

20. Tooth Upper right Upper left Ideal
Central I 9.1 9.3 8.85
Lateral I 7.4 7.4 6.9
Canine 8.2 8.1 7.88
Tooth Lower right Lower left Ideal
Central I 5.4 5.3 5.5
Lateral I 6.3 6.3 6
Canine 6.9 6.9 6.95
∑UA = 49.5 mm
∑LA = 37.1 mm
∑LA / ∑UA = 37.1/49.5 = 74.9% (norm=77%)
Pre-treatment

21.  DENTAL:
 Position of the upper incisor in the relation to the maxilla (18, N = 23 ± 6): upper incisors
slightly retroclined
 Position of the lower incisor in relation to the mandible (27, N = 27.5 ± 5): normal
 Lower incisor to the mandibular plane (98, N = 91.4 ± 4) : slightly proclined in relation to
mandibular plane
 Interincisal angle (129.4, N =130 ± 7): normal
 SKELETAL:
 Position of the maxilla in relation to the cranial base (SNA = 86, N = 81± 3): slightly
prognathic maxilla
 Position of the mandible on relation to the cranial base (SNB = 80.5, N = 78 ± 3): normal
 Relationship of the mandible and maxilla (ANB = 5.5, N = 3± 2): normal (CI skeletal
pattern)
 (Witts -0.8, 2± 2): normal (CI / slight C3 skeletal pattern)
 Facial angle = 91.2, N = 88 ± 4: normal, slight vertical growth pattern
 Mandibular plane angle (30, N = 33 ± 3): normal
 Y axis (62, N = 60 ±4): normal growth pattern
Pre-treatment

22.  Class I, type I malocclusion
 Very slight convex profile
 Crossbite (1.2 / 4.2)
 40-50 % overbite
 4mm (R) and 2mm (L) overjet
 Crowding in the anterior permanent teeth in
both dental arches
 Dento-alveolar / tooth mass discrepancy
 Several rotated teeth
 Lower dental midline shifted 3 mm to the
right
Pre-treatment

23.  Maintain Class I occlusion
 Alleviate crowding
 Align anterior teeth
 Correct deviated dental midline
 Maintain overbite and overjet
 Preserve facial profile
 Address patient’s chief complaint and satisfy
patient expectations (realistically)

25.  Invisalign on both arches
- align/coordinate upper and lower arches
- relieve anterior crossbite (Q1 / 4)
- de-rotate teeth with the use of attachment buttons
 Interproximal stripping
- aid in creating space and relieving the crowding
present
- shift the lower anteriors towards the left correcting
dental midline shift

26.  NiTi archwire upper arch 2x4 only
- align/coordinate upper and lower arches
and midlines
- de-rotate and align teeth
 Interproximal stripping
- correct the moderate crowding present
- shift the lower anteriors towards the
left correcting dental midline shift

27.  Extraction of upper and lower first
premolars
 Complete bracketing of the upper arch and
lower arch
- relieve crowding
- de-rotate and align teeth
- coordinate upper and lower
arches/midlines

28.  Patient did not want upper and lower
bracketing
 Complete bracketing is not done at the McGill
Undergraduate Dental Clinic
 Selected:
“Compromised Treatment Option #1”
Invisalign with interproximal reduction
- align teeth and both arches / midlines
- relieve anterior crossbite

29. No mid-treatment phase: patient completed
treatment plan by orthodontist and Invisalign

30. Total treatment time: 1 year, 5 months

31.  Age: 18 years old
 Sex: female
 Post-Tx perspective:
Patient is very happy with
treatment results.
- However, there are a few things that
she would like to modify (later).
Post-treatment

32.  No change from pre-treatment
 Facial Profile:  Nasolabial angle:  Lips:
Slightly convex Slightly obtuse Upper lip normal
Lips normal at rest
No upper incisors show at
rest

33. Right Side Dental Midline Left Side
Molar class I Upper: no deviation Molar class I
Canine class I Lower: no deviation Canine class I
Post-treatment

34. Pre-treatment Post-treatment
40-50 % Overbite 15 % Overbite
Post-treatment

35. Overjet
Right: 4 mm Left: 2 mm Right: 1 mm Left: 1 mm
Pre-treatment Post-treatment

36.  Arch Shape
Normal
Normal
Normal Normal
Pre-treatment Post-treatment

37.  Crowding
Moderate Normal
Mild-Moderate Normal
Pre-treatment Post-treatment

38.  Crossbite fixed (1.2 / 4.2)
 Crowding alleviated in both arches (due to
rotated and misaligned teeth)
 Dental midline corrected (only 0.5mm
deviation to the right)
 Overbite slightly reduced (only 15%)
 Overjet evened out to 1mm right and left
Post-treatment

39. Permanent Dentition: Symmetric mandible; 8’s unerupted
Normal condylar and skeletal architecture
Post-treatment

40. Measurement Value Normal SD
SKELETAL
SNA 87 81º 3
SNB 83 78 3
ANB 4 3 2
Facial Angle 87 88 4
Witts 1 2 2
Mand. Plane Angle 30 33 3
Y axis 64 60 4
DENTO-ALVEOLAR
Upper inc. to NA 22 23 6
Lower inc. to NB 26 27.5 5
Upper inc./Lower 127 130 7
inc
Lower Inc. to 94 91.4 4
Mand. Plane
Post-treatment

41. Pre-treatment Post-treatment
Measurement Value Normal SD Measurement Value Normal SD
SKELETAL SKELETAL
SNA 86 81º 3 SNA 87 81º 3
SNB 80.5 78 3 SNB 83 78 3
ANB 5.5 3 2 ANB 4 3 2
Facial Angle 91.2 88 4 Facial Angle 87 88 4
Witts -0.8 2 2 Witts 1 2 2
Mand. Plane Angle 30 33 3 Mand. Plane Angle 32 33 3
Y axis 62 60 4 Y axis 64 60 4
DENTO-ALVEOLAR DENTO-ALVEOLAR
Upper inc. to NA 18 23 6 Upper inc. to NA 22 23 6
Lower inc. to NB 27 27.5 5 Lower inc. to NB 26 27.5 5
Upper inc./Lower inc 129.4 130 7 Upper inc./Lower inc 127 130 7
Lower Inc. to Mand. Plane 98 91.4 4 Lower Inc. to Mand. Plane 94 91.4 4

42.  Normal Curve of Spee
Post-treatment

43. Molar rotation: 16 (normal), 26 (normal)
36 (normal), 46 (distally - mild)
Angle Classification:
Right: Class I molar, class I canine
Left: Class I molar, class I canine
Overbite 15 %
Overjet 1 mm (right), 1 mm (left)
Post-treatment

44.  Abnormal tip: 12, 13, 14, 22
 Abnormal torque: 12, 13
 Rotation (molar): 46 (distally – mild)
Post-treatment

45. Tooth Upper right Upper left Ideal
Central I 8.7 8.8 8.85
Lateral I 7.0 7.1 6.9
Canine 7.6 7.8 7.88
Tooth Lower right Lower left Ideal
Central I 5.3 5.3 5.5
Lateral I 5.9 6.0 6
Canine 6.8 6.8 6.95
∑UA = 47 mm
∑LA = 36.1 mm
∑LA / ∑UA = 36.1/47 = 76.8% (norm=77%)
Post-treatment

46.  DENTAL:
 Position of the upper incisor in the relation to the maxilla (22, N = 23 ± 6): normal
 Position of the lower incisor in relation to the mandible (26, N = 27.5 ± 5): normal
 Lower incisor to the mandibular plane (94, N = 91.4 ± 4) : normal
 Interincisal angle (127, N =130 ± 7): normal
 SKELETAL:
 Position of the maxilla in relation to the cranial base (SNA = 87, N = 81± 3): slightly
prognathic maxilla
 Position of the mandible on relation to the cranial base (SNB = 83, N = 78 ± 3):
slightly prognathic mandible
 Relationship of the mandible and maxilla (ANB = 4, N = 3± 2): normal (CI skeletal
pattern)
 (Witts 1, 2± 2): normal (CI skeletal pattern)
 Facial angle = 87, N = 88 ± 4: normal
 Mandibular plane angle (32, N = 33 ± 3): normal
 Y axis (64, N = 60 ±4): normal / slight vertical growth pattern tendency
Post-treatment

47.  Slight convex profile
 Class I molars and canines (right & left)
 Vertical growth pattern tendency
 Increased lower face height
Post-treatment

48.  Patient is not satisfied with appearance of teeth
1.2 and 1.3 (slightly rotated and lingually
inclined)
 She also feels that her 2 upper central incisors
look “big”.
Post-treatment

49.  Invisalign Refinement Trays
 New Invisalgn impressions, Jetbite registration, photos, Panorex
and Cephalometric radiographs were taken
 Special instructions sent for tray fabrication:
 1.2: labial root torque, rotation of mesial contact point into proper
contact, extrusion of 1mm; possibly IPR
 1.3: labial root torque, extrusion
 2.2: rotation of contact point mesially
 Refine 1st and 2nd premolars into occlusion
 Possible re-alignment of dental midlines (at present, 0.5mm to the
right)
Post-treatment