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Special Issues
July/August 2022
Volume 43, Issue 1

Aligner Therapy Central Component of Digital Workflow Plan

Jeffrey Briney, DDS

A 34-year-old healthy man presented to the author's practice after having multiple consultations with a general practitioner and orthodontists who all told him that aligner therapy could not resolve his dental issues. The patient's maxillary right lateral incisor was congenitally missing, contributing to his concerns about the overall appearance of his smile, and he also complained of what he believed to be temporomandibular joint (TMJ) pain. Upon examination of the patient and radiographs, the author determined that the patient's occlusal disease had resulted from the collapse of the maxillary teeth on his right side and the lingually inclined premolars and anterior teeth, leading to moderate abfractions throughout his mouth and a myofascial pain disorder that the patient had mistaken for a TMJ problem. A treatment plan was presented to both correct his cosmetic concerns and also address his "silent" occlusal disease and myofascial pain disorder. The treatment would begin with orthodontic positioning of his teeth into an ideal occlusion via ClearCorrect® aligner therapy (Straumann, clearcorrect.com) and then, after 9 months of aligner therapy, proceed to the surgical and restorative phases. The case was completed in 12 months using a digital workflow plan that involved the use of intraoral scanning, CBCT, in-office milling for a surgical guide and restorations, and orthodontic software (ClearPilot™, Straumann).

Key Takeaways

Clear aligner orthodontics has progressed to allow for advanced teeth movements in a relatively short time compared to traditional brackets and wires.

ClearPilot digital treatment design tool affords clinicians improved visualization and responsive control when reviewing and approving their ClearCorrect aligner cases.

This case involving a congenitally missing maxillary right lateral incisor centered around 9 months of clear aligner therapy and included implant placement and restoration utilizing a digital workflow.

About the Author

Jeffrey Briney, DDS
Private Practice, Dana Point, California

Fig 1. Full-face photograph before treatment. The patient said that he needed to force his smile because of a lack of confidence about the appearance of his dentition.

Figure 1

Fig 2. Pretreatment panoramic radiograph revealed a lack of space for implant placement at No. 7, open interproximal spaces throughout the maxillary arch with rotations, and crowding in the mandibular region.

Figure 2

Fig 3. Anterior retracted view before treatment, demonstrating 3.5 mm midline shift to the patient’s right side. Occlusal disease with general abfractions was evident in the premolar and canine regions in all four quadrants. Axial inclination of the maxillary anterior teeth and premolars converged toward the patient’s chin.

Figure 3

Fig 4. Maxillary occlusal view before treatment.

Figure 4

Fig 5. Initial ClearPilot treatment setup with 15 sets of aligners planned.

Figure 5

Fig 6. Estimated movement by aligner No. 7 with only four engagers and no interproximal reduction.

Figure 6

Fig 7. Estimated result at aligner No. 15 prior to the surgical treatment plan, which would involve a CBCT, in-office milled surgical guide, and implant placement.

Figure 7

Fig 8. Anterior retracted view after 4 months of ClearCorrect aligner therapy (aligner No. 7). Note the accuracy when comparing the estimated movement shown in the ClearPilot treatment setup for aligner No. 7 (Figure 6) and the actual result at aligner No. 7, shown here.

Figure 8

Fig 9. After use of aligner No. 12, new digital scans were taken to add a “virtual pontic” for cosmetic purposes (composite added into the aligner at missing tooth No. 7) and ideal positioning for anticipated implant placement at month 9. Aligners Nos. 13 through 15 were not ordered. A new treatment plan increased the number of sets of aligners from the original 15 to 20.

Figure 9

Fig 10. Placement of a 3.3-mm diameter implant (Straumann) at month 9 via a digital workflow involving the use of an intraoral scanner, CBCT, in-office milled surgical guide, and laser. The patient still had to complete three more sets of aligners to allow osseointegration to occur prior to restoration. The patient wore each set of aligners for 14 days and the final set (No. 20) for 30 days.

Figure 10

Fig 11. One week after uncovering the implant, a custom e.max® abutment (Ivoclar Vivadent, ivoclarvivadent.com) was fabricated via CEREC® TiBase (Dentsply Sirona, dentsplysirona.com) approach.

Figure 11

Fig 12. An e.max temporary crown was placed during the same appointment as the placement of the custom abutment prior to in-office whitening and Class V restorations.

Figure 12

Fig 13. Final panoramic radiograph.

Figure 13

Fig 14. Final full-face photograph 12 months after start of treatment.

Figure 14

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