Improving Protrusion & Profile: Non-Extraction With Invisalign
12y 5m female
SUBJECTIVE: A 12y 5m female was seen (with mom) for an evaluation. The patient had primary concerns with her two front teeth.
OBJECTIVE: Her exam revealed a half cusp Class II molar and canine relationship on both sides. She had excess overjet (5mm) and a deep bite (5mm). Both upper and lower incisors were proclined and protrusive relative to their skeletal bases. Her lips were full, protrusive to the E-plane, and she demonstrated lip-incompetence (evidenced by the flattened mentalis region - chin - on her ceph).
There was mild upper and lower spacing, no anterior or posterior cross bites, and radiographs held no significant findings other than previously discussed.
ASSESSMENT: Treatment goals were to:
- Close all spacing, level and align the upper and lower arches.
- Correct right and left sides to Class I canine and molar.
- Improve the profile by decreasing lip protrusion and incompetence via retroclination and retraction of the upper & lower incisors.
PLAN:
- Comprehensive treatment for 14 to 18 months using Invisalign clear aligners OR Damon brackets.
- Option 1: Non-extraction, IPR as needed to retrocline & retract incisors as much as possible.
- Option 2: Extraction of all first premolars, space closure, retraction, and retroclination of incisors.
- Parents and patient preferred and selected the non-extraction treatment approach.
Treatment
We delivered initial Invisalign aligners December 2022 with instructions to wear 22+ hours per day and to change trays every 10 days to allow accurate incisor tracking.
She was seen back 2 months later, demonstrated excellent tracking, and we began rubber bands for Class II correction. We saw her back at regular intervals throughout her first set of trays, continuing 10 day tray changes. November 2023 we scanned for additional trays.
Her 14 refinement trays were delivered December 2023 with instructions to change trays weekly. At tray 12 her bite was still off so we scanned for additional trays.
Her final set of trays was delivered March 2024, slight IPR was performed to aid in Bolton Discrepancy correction, and continuation of elastics for bite correction. Subsequent follow ups continued to demonstrate excellent tracking. October 2024 patient and parent were satisfied and ready to be done. We removed attachments and took final records, with upper and lower Vivera retainers being delivered 2 weeks later.
Treatment Review
This case took me a little longer than I anticipated as I was hoping to get everything absolutely perfect. Unfortunately, there were a few things that missed the mark. The final anterior photo shows how the lower midline is slightly off to the right and the slight dark triangle between the upper centrals. The upper 2nd premolars also needed more buccal root torque as the buccal surface shows some “flaring”, especially #4.
The patient had excellent Class II correction which helped decrease the overjet. Her compliance resulted in phenomenal retroclination and relative retraction of the upper and lower incisors. With the incisor movement, her lips became less protrusive and more competent (as evidenced by the decreased mentalis strain at her chin in the lateral ceph). During retroclination it is easy to deepen the bite inadvertently from “relative extrusion”, however her overbite was ideal upon completion.
Overall, I was very pleased with the outcome, and her smile radiated upon completion. Being able to control the torque, and also the vertical movement (intrusion) of the incisors through some creative staging of Invisalign was exciting as many detractors of Invisalign tout its inability to efficiently/effectively address torque issues.