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Contemporary ortho chap18 part2
 

Contemporary ortho chap18 part2

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20130115 beethoven orthodontic course

20130115 beethoven orthodontic course
textbook review
Contemporary ortho 5e
chap 18
part 2

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    Contemporary ortho chap18 part2 Contemporary ortho chap18 part2 Presentation Transcript

    • CHAPTER 18Special Considerations in Treatment for Adults, 623William R. Proffit, David M. SarverAdjunctive vs Comprehensive Treatment, 624Goals of Adjunctive Treatment, 624Principles of Adjunctive Treatment, 624Adjunctive Treatment Procedures, 627Comprehensive Treatment in Adults, 637Special Aspects of Orthodontic Therapy for Adults,661
    • which is often further complicated by irregularspacing related to small or missing lateral incisors(Figure 18-20). A "diagnostic setup" is very helpfulin planning the correction of such problems. For thisAlignment of Anterior Teethprocedure, the study casts are duplicated and themalaligned teeth are carefully cut from the model,repositioned, and then waxed back onto the cast in anew position. If digital casts are available, a modernalternative is to do this on a computer screen (seeFigure14-1), and this is part of routine treatmentplanning when a sequence of clear aligners will beused in comprehensive treatment (see below). Thisallows evaluation of the feasibility of the orthodontictreatment in light of the crown and root movementsrequired, the anchorage available, the periodontal FIGURE 18-20support for each tooth, and the possible occlusalinterferences. If spacing of maxillary incisors is related to small teeth and a tooth-size discrepancy, composite buildups are an excellent The major indication for adjunctive orthodontic solution, but satisfactory esthetics may require redistribution oftreatment to correct malaligned anterior teeth is the space before the restorations are placed, as in this patient whopreparation for buildups, veneers, or implants to was concerned about his large central diastema. A and B, Before treatment, age 48. C and D, Redistribution of the space using aimprove the appearance of the maxillary incisor teeth. fixed appliance with coil springs on a 16 mil steel archwireThe most frequent problem is a maxillary central immediately before removal of the orthodontic appliance anddiastema, which is often further complicated by placement of the restorations (to be done the same day). A17.5 mil multistrand steel wire was used for initial alignment before theirregular spacing related to small or missing lateral coil springs were placed. Eand F, Completed restorationsincisors (Figure 18-20). A "diagnostic setup" is very (composite buildups). G, Note the fixed retainer of bonded 21.5helpful in planning the correction of such problems. mil multistrand wire on the lingual of the central incisors to prevent partial reopening of the midline space. Surgical revision ofFor this procedure, the study casts are duplicated and the frenum was not performed, partially in deference to thethe malaligned teeth are carefully cut from the model, patients age. H, Appearance on smile before and (I) afterrepositioned, and then waxed back onto the cast in a treatment.new position. If digital casts are available, a modern636
    • which is often further complicated by irregularspacing related to small or missing lateral incisors(Figure 18-20). A "diagnostic setup" is very helpfulin planning the correction of such problems. For thisAlignment of Anterior Teethprocedure, the study casts are duplicated and themalaligned teeth are carefully cut from the model,repositioned, and then waxed back onto the cast in anew position. If digital casts are available, a modernalternative is to do this on a computer screen (see Ortho. Closure ?Figure14-1), and this is part of routine treatmentplanning when a sequence of clear aligners will beused in comprehensive treatment (see below). This Restorations ?allows evaluation of the feasibility of the orthodontictreatment in light of the crown and root movementsrequired, the anchorage available, the periodontal FIGURE 18-20support for each tooth, and the possible occlusalinterferences. If spacing of maxillary incisors is related to small teeth and a tooth-size discrepancy, composite buildups are an excellent The major indication for adjunctive orthodontic solution, but satisfactory esthetics may require redistribution oftreatment to correct malaligned anterior teeth is the space before the restorations are placed, as in this patient whopreparation for buildups, veneers, or implants to was concerned about his large central diastema. A and B, Before treatment, age 48. C and D, Redistribution of the space using aimprove the appearance of the maxillary incisor teeth. fixed appliance with coil springs on a 16 mil steel archwireThe most frequent problem is a maxillary central immediately before removal of the orthodontic appliance anddiastema, which is often further complicated by placement of the restorations (to be done the same day). A17.5 mil multistrand steel wire was used for initial alignment before theirregular spacing related to small or missing lateral coil springs were placed. Eand F, Completed restorationsincisors (Figure 18-20). A "diagnostic setup" is very (composite buildups). G, Note the fixed retainer of bonded 21.5helpful in planning the correction of such problems. mil multistrand wire on the lingual of the central incisors to prevent partial reopening of the midline space. Surgical revision ofFor this procedure, the study casts are duplicated and the frenum was not performed, partially in deference to thethe malaligned teeth are carefully cut from the model, patients age. H, Appearance on smile before and (I) afterrepositioned, and then waxed back onto the cast in a treatment.new position. If digital casts are available, a modern636
    • which is often further complicated by irregularspacing related to small or missing lateral incisors(Figure 18-20). A "diagnostic setup" is very helpfulin planning the correction of such problems. For thisAlignment of Anterior Teethprocedure, the study casts are duplicated and themalaligned teeth are carefully cut from the model,repositioned, and then waxed back onto the cast in anew position. If digital casts are available, a modernalternative is to do this on a computer screen (see Ortho. Closure ?Figure14-1), and this is part of routine treatmentplanning when a sequence of clear aligners will beused in comprehensive treatment (see below). This Restorations ?allows evaluation of the feasibility of the orthodontictreatment in light of the crown and root movementsrequired, the anchorage available, the periodontal FIGURE 18-20support for each tooth, and the possible occlusalinterferences. If spacing of maxillary incisors is related to small teeth and a Diagnostic Setup The major indication for adjunctive orthodontictreatment to correct malaligned anterior teeth is tooth-size discrepancy, composite buildups are an excellent solution, but satisfactory esthetics may require redistribution of the space before the restorations are placed, as in this patient whopreparation for buildups, veneers, or implants to was concerned about his large central diastema. A and B, Before treatment, age 48. C and D, Redistribution of the space using aimprove the appearance of the maxillary incisor teeth. fixed appliance with coil springs on a 16 mil steel archwireThe most frequent problem is a maxillary central immediately before removal of the orthodontic appliance anddiastema, which is often further complicated by placement of the restorations (to be done the same day). A17.5 mil multistrand steel wire was used for initial alignment before theirregular spacing related to small or missing lateral coil springs were placed. Eand F, Completed restorationsincisors (Figure 18-20). A "diagnostic setup" is very (composite buildups). G, Note the fixed retainer of bonded 21.5helpful in planning the correction of such problems. mil multistrand wire on the lingual of the central incisors to prevent partial reopening of the midline space. Surgical revision ofFor this procedure, the study casts are duplicated and the frenum was not performed, partially in deference to thethe malaligned teeth are carefully cut from the model, patients age. H, Appearance on smile before and (I) afterrepositioned, and then waxed back onto the cast in a treatment.new position. If digital casts are available, a modern636
    • which is often further complicated by irregular spacing related to small or missing lateral incisors (Figure 18-20). A "diagnostic setup" is very helpful in planning the correction of such problems. For this Alignment of Anterior Teeth procedure, the study casts are duplicated and the malaligned teeth are carefully cut from the model, repositioned, and then waxed back onto the cast in a new position. If digital casts are available, a modern alternative is to do this on a computer screen (see Figure14-1), and this is part of routine treatment planning when a sequence of clear aligners will be used in comprehensive treatment (see below). This allows evaluation of the feasibility of the orthodontic treatment in light of the crown and root movementsª›®œ•Œ QuickTime˛ ©M required, the anchorage available, the periodontal °ß°®∏—¿£¡Yæπ ®”¿Àµ¯¶ππœµe°C support for each tooth, and the possible occlusal interferences. If spacing of maxillary incisors is related to small teeth and a tooth-size discrepancy, composite buildups are an excellent The major indication for adjunctive orthodontic solution, but satisfactory esthetics may require redistribution of treatment to correct malaligned anterior teeth is the space before the restorations are placed, as in this patient who preparation for buildups, veneers, or implants to was concerned about his large central diastema. A and B, Before treatment, age 48. C and D, Redistribution of the space using a improve the appearance of the maxillary incisor teeth. fixed appliance with coil springs on a 16 mil steel archwire The most frequent problem is a maxillary central immediately before removal of the orthodontic appliance and diastema, which is often further complicated by placement of the restorations (to be done the same day). A17.5 mil multistrand steel wire was used for initial alignment before the irregular spacing related to small or missing lateral coil springs were placed. Eand F, Completed restorations incisors (Figure 18-20). A "diagnostic setup" is very (composite buildups). G, Note the fixed retainer of bonded 21.5 helpful in planning the correction of such problems. mil multistrand wire on the lingual of the central incisors to prevent partial reopening of the midline space. Surgical revision of For this procedure, the study casts are duplicated andFIGURE 14-1 Pre-Tx. Dx. Setup or Digital simulation Pre-Tx. Dx. Setup or Digital simulation the malaligned teeth are carefully cut from the model, repositioned, and then waxed back onto the cast in a the frenum was not performed, partially in deference to the patients age. H, Appearance on smile before and (I) after treatment. new position. If digital casts are available, a modern636
    • which is often further complicated by irregularspacing related to small or missing lateral incisors(Figure 18-20). A "diagnostic setup" is very helpfulin planning the correction of such problems. For thisAlignment of Anterior Teethprocedure, the study casts are duplicated and themalaligned teeth are carefully cut from the model,repositioned, and then waxed back onto the cast in anew position. If digital casts are available, a modernalternative is to do this on a computer screen (seeFigure14-1), and this is part of routine treatmentplanning when a sequence of clear aligners will beused in comprehensive treatment (see below). Thisallows evaluation of the feasibility of the orthodontictreatment in light of the crown and root movementsrequired, the anchorage available, the periodontalsupport for each tooth, and the possible occlusalinterferences. If spacing of maxillary incisors is related to small teeth and a tooth-size discrepancy, composite buildups are an excellent The major indication for adjunctive orthodontic solution, but satisfactory esthetics may require redistribution oftreatment to correct malaligned anterior teeth is the space before the restorations are placed, as in this patient whopreparation for buildups, veneers, or implants to was concerned about his large central diastema. A and B, Before treatment, age 48. C and D, Redistribution of the space using aimprove the appearance of the maxillary incisor teeth. fixed appliance with coil springs on a 16 mil steel archwireThe most frequent problem is a maxillary central immediately before removal of the orthodontic appliance anddiastema, which is often further complicated by placement of the restorations (to be done the same day). A17.5 mil multistrand steel wire was used for initial alignment before theirregular spacing related to small or missing lateral coil springs were placed. Eand F, Completed restorationsincisors (Figure 18-20). A "diagnostic setup" is very (composite buildups). G, Note the fixed retainer of bonded 21.5helpful in planning the correction of such problems. mil multistrand wire on the lingual of the central incisors to prevent partial reopening of the midline space. Surgical revision ofFor this procedure, the study casts are duplicated and the frenum was not performed, partially in deference to thethe malaligned teeth are carefully cut from the model, FIGURE 18-20 patients age. H, Appearance on smile before and (I) afterrepositioned, and then waxed back onto the cast in a treatment.new position. If digital casts are available, a modern636
    • which is often further complicated by irregularspacing related to small or missing lateral incisors(Figure 18-20). A "diagnostic setup" is very helpfulin planning the correction of such problems. For thisAlignment of Anterior Teethprocedure, the study casts are duplicated and themalaligned teeth are carefully cut from the model,repositioned, and then waxed back onto the cast in anew position. If digital casts are available, a modernalternative is to do this on a computer screen (seeFigure14-1), and this is part of routine treatmentplanning when a sequence of clear aligners will beused in comprehensive treatment (see below). Thisallows evaluation of the feasibility of the orthodontictreatment in light of the crown and root movements 16 mil steelrequired, the anchorage available, the periodontalsupport for each tooth, and the possible occlusalinterferences. If spacing of maxillary incisors is related to small teeth and a tooth-size discrepancy, composite buildups are an excellent The major indication for adjunctive orthodontic solution, but satisfactory esthetics may require redistribution oftreatment to correct malaligned anterior teeth is the space before the restorations are placed, as in this patient whopreparation for buildups, veneers, or implants to was concerned about his large central diastema. A and B, Before treatment, age 48. C and D, Redistribution of the space using aimprove the appearance of the maxillary incisor teeth. fixed appliance with coil springs on a 16 mil steel archwireThe most frequent problem is a maxillary central immediately before removal of the orthodontic appliance anddiastema, which is often further complicated by placement of the restorations (to be done the same day). A17.5 mil multistrand steel wire was used for initial alignment before theirregular spacing related to small or missing lateral coil springs were placed. Eand F, Completed restorationsincisors (Figure 18-20). A "diagnostic setup" is very (composite buildups). G, Note the fixed retainer of bonded 21.5helpful in planning the correction of such problems. mil multistrand wire on the lingual of the central incisors to prevent partial reopening of the midline space. Surgical revision ofFor this procedure, the study casts are duplicated and the frenum was not performed, partially in deference to thethe malaligned teeth are carefully cut from the model, FIGURE 18-20 patients age. H, Appearance on smile before and (I) afterrepositioned, and then waxed back onto the cast in a treatment.new position. If digital casts are available, a modern636
    • which is often further complicated by irregularspacing related to small or missing lateral incisors(Figure 18-20). A "diagnostic setup" is very helpfulin planning the correction of such problems. For thisAlignment of Anterior Teethprocedure, the study casts are duplicated and themalaligned teeth are carefully cut from the model,repositioned, and then waxed back onto the cast in anew position. If digital casts are available, a modernalternative is to do this on a computer screen (seeFigure14-1), and this is part of routine treatmentplanning when a sequence of clear aligners will beused in comprehensive treatment (see below). Thisallows evaluation of the feasibility of the orthodontictreatment in light of the crown and root movementsrequired, the anchorage available, the periodontalsupport for each tooth, and the possible occlusalinterferences. If spacing of maxillary incisors is related to small teeth and a tooth-size discrepancy, composite buildups are an excellent The major indication for adjunctive orthodontic solution, but satisfactory esthetics may require redistribution oftreatment to correct malaligned anterior teeth is the space before the restorations are placed, as in this patient whopreparation for buildups, veneers, or implants to was concerned about his large central diastema. A and B, Before treatment, age 48. C and D, Redistribution of the space using aimprove the appearance of the maxillary incisor teeth. fixed appliance with coil springs on a 16 mil steel archwireThe most frequent problem is a maxillary central immediately before removal of the orthodontic appliance anddiastema, which is often further complicated by placement of the restorations (to be done the same day). A17.5 mil multistrand steel wire was used for initial alignment before theirregular spacing related to small or missing lateral coil springs were placed. Eand F, Completed restorationsincisors (Figure 18-20). A "diagnostic setup" is very (composite buildups). G, Note the fixed retainer of bonded 21.5helpful in planning the correction of such problems. mil multistrand wire on the lingual of the central incisors to prevent partial reopening of the midline space. Surgical revision ofFor this procedure, the study casts are duplicated and the frenum was not performed, partially in deference to thethe malaligned teeth are carefully cut from the model, FIGURE 18-20 patients age. H, Appearance on smile before and (I) afterrepositioned, and then waxed back onto the cast in a treatment.new position. If digital casts are available, a modern636
    • which is often further complicated by irregularspacing related to small or missing lateral incisors(Figure 18-20). A "diagnostic setup" is very helpfulin planning the correction of such problems. For thisAlignment of Anterior Teethprocedure, the study casts are duplicated and themalaligned teeth are carefully cut from the model,repositioned, and then waxed back onto the cast in anew position. If digital casts are available, a modernalternative is to do this on a computer screen (seeFigure14-1), and this is part of routine treatmentplanning when a sequence of clear aligners will beused in comprehensive treatment (see below). Thisallows evaluation of the feasibility of the orthodontictreatment in light of the crown and root movements 21.5 milrequired, the anchorage available, the periodontalsupport for each tooth, and the possible occlusalinterferences. If spacing of maxillary incisors is related to small teeth and a tooth-size discrepancy, composite buildups are an excellent The major indication for adjunctive orthodontic solution, but satisfactory esthetics may require redistribution oftreatment to correct malaligned anterior teeth is the space before the restorations are placed, as in this patient whopreparation for buildups, veneers, or implants to was concerned about his large central diastema. A and B, Before treatment, age 48. C and D, Redistribution of the space using aimprove the appearance of the maxillary incisor teeth. fixed appliance with coil springs on a 16 mil steel archwireThe most frequent problem is a maxillary central immediately before removal of the orthodontic appliance anddiastema, which is often further complicated by placement of the restorations (to be done the same day). A17.5 mil multistrand steel wire was used for initial alignment before theirregular spacing related to small or missing lateral coil springs were placed. Eand F, Completed restorationsincisors (Figure 18-20). A "diagnostic setup" is very (composite buildups). G, Note the fixed retainer of bonded 21.5helpful in planning the correction of such problems. mil multistrand wire on the lingual of the central incisors to prevent partial reopening of the midline space. Surgical revision ofFor this procedure, the study casts are duplicated and the frenum was not performed, partially in deference to thethe malaligned teeth are carefully cut from the model, FIGURE 18-20 patients age. H, Appearance on smile before and (I) afterrepositioned, and then waxed back onto the cast in a treatment.new position. If digital casts are available, a modern636
    • Alignment of Anterior TeethCrowded, Rotated, and Displaced Incisors As arule, spacing is the problem when maxillary incisorsneed realignment to facilitate other treatment. FIGURE 18-21Crowding usually is the problem when alignment of In an adult with a damaged lower incisor (in this case, the left centrallower incisors is considered to provide access for incisor with a crown fracture) and incisor crowding, there are tworestorations, achieve better occlusion, or enable the treatment possibilities: extract the damaged tooth and use the space to align the remaining teeth, or align the teeth with arch expansion andpatient to maintain the teeth. In some cases, restore the damaged one. The decision has an esthetic componentalignment of incisors in both arches must be because the lower incisors are visible on smile in older individuals. In this patient, aligning the lower incisors without extraction would alsoconsidered. The key question is whether the require aligning the upper incisors, but this expansion would increasecrowding should be resolved by expanding the arch, lip support and improve the overall facial appearance as well as theremoving some interproximal enamel from each dental appearance. A, Smile before treatment, after loss of one corner of the lower right central incisor. B, Mandibular occlusal view. C, Frontaltooth to provide space,8 or removing one lower view. Note the moderately deep bite and lack of overjet. The restorativeincisor. Expansion of a crowded incisor segment dentist sought orthodontic consultation, thinking that extraction of thecan be done with clear aligners, but if only the damaged tooth might be the best plan. The patient wanted the best esthetic result and accepted a period of treatment with a fixed appliancelower arch is to be treated, the esthetics of the on both arches, after which the incisor would be restored. Theappliance is not a consideration, and a partial fixed orthodontic alignment required 5 months. 0, Mandibular occlusal view after alignment. E, Frontal view. F, Smile after restoration wasappliance is more efficient and cost-effective completed.(Figure 18-21). A segment of A-NiTi wire, withstops to make it slightly advanced, usually is thebest way to bring the teeth into alignment (seeFigure 14-5). FIGURE 14-5). 637
    • Alignment of Anterior TeethCrowded, Rotated, and Displaced Incisors As arule, spacing is the problem when maxillary incisorsneed realignment to facilitate other treatment. FIGURE 18-21Crowding usually is the problem when alignment of In an adult with a damaged lower incisor (in this case, the left centrallower incisors is considered to provide access for incisor with a crown fracture) and incisor crowding, there are tworestorations, achieve better occlusion, or enable the treatment possibilities: extract the damaged tooth and use the space to Ext. ?patient to maintain the teeth. In some cases, align the remaining teeth, or align the teeth with arch expansion and restore the damaged one. The decision has an esthetic componentalignment of incisors in both arches must be because the lower incisors are visible on smile in older individuals. In Expansion?considered. The key question is whether the this patient, aligning the lower incisors without extraction would also require aligning the upper incisors, but this expansion would increasecrowding should be resolved by expanding the arch, Inter-proximal Reductionremoving some interproximal enamel from each lip support and improve the overall facial appearance as well as the dental appearance. A, Smile before treatment, after loss of one corner of the lower right central incisor. B, Mandibular occlusal view. C, Frontalincisor. (IPR)?tooth to provide space,8 or removing one lower Expansion of a crowded incisor segment view. Note the moderately deep bite and lack of overjet. The restorative dentist sought orthodontic consultation, thinking that extraction of thecan be done with clear aligners, but if only the damaged tooth might be the best plan. The patient wanted the best esthetic result and accepted a period of treatment with a fixed appliancelower arch is to be treated, the esthetics of the on both arches, after which the incisor would be restored. Theappliance is not a consideration, and a partial fixed orthodontic alignment required 5 months. 0, Mandibular occlusal view after alignment. E, Frontal view. F, Smile after restoration wasappliance is more efficient and cost-effective completed.(Figure 18-21). A segment of A-NiTi wire, withstops to make it slightly advanced, usually is thebest way to bring the teeth into alignment (seeFigure 14-5). FIGURE 14-5). 637
    • Alignment of Anterior TeethCrowded, Rotated, and Displaced Incisors As arule, spacing is the problem when maxillary incisorsneed realignment to facilitate other treatment.Crowding usually is the problem when alignment of In an adult with a damaged lower incisor (in this case, the left centrallower incisors is considered to provide access for incisor with a crown fracture) and incisor crowding, there are tworestorations, achieve better occlusion, or enable the treatment possibilities: extract the damaged tooth and use the space to align the remaining teeth, or align the teeth with arch expansion andpatient to maintain the teeth. In some cases, restore the damaged one. The decision has an esthetic componentalignment of incisors in both arches must be because the lower incisors are visible on smile in older individuals. In this patient, aligning the lower incisors without extraction would alsoconsidered. The key question is whether the require aligning the upper incisors, but this expansion would increasecrowding should be resolved by expanding the arch, lip support and improve the overall facial appearance as well as theremoving some interproximal enamel from each dental appearance. A, Smile before treatment, after loss of one corner of the lower right central incisor. B, Mandibular occlusal view. C, Frontaltooth to provide space,8 or removing one lower view. Note the moderately deep bite and lack of overjet. The restorativeincisor. Expansion of a crowded incisor segment dentist sought orthodontic consultation, thinking that extraction of thecan be done with clear aligners, but if only the damaged tooth might be the best plan. The patient wanted the best esthetic result and accepted a period of treatment with a fixed appliancelower arch is to be treated, the esthetics of the on both arches, after which the incisor would be restored. Theappliance is not a consideration, and a partial fixed orthodontic alignment required 5 months. 0, Mandibular occlusal view after alignment. E, Frontal view. F, Smile after restoration wasappliance is more efficient and cost-effective completed.(Figure 18-21). A segment of A-NiTi wire, withstops to make it slightly advanced, usually is thebest way to bring the teeth into alignment (seeFigure 14-5). FIGURE 14-5 FIGURE 18-21). 637
    • Alignment of Anterior TeethCrowded, Rotated, and Displaced Incisors As arule, spacing is the problem when maxillary incisorsneed realignment to facilitate other treatment.Crowding usually is the problem when alignment of In an adult with a damaged lower incisor (in this case, the left centrallower incisors is considered to provide access for incisor with a crown fracture) and incisor crowding, there are tworestorations, achieve better occlusion, or enable the treatment possibilities: extract the damaged tooth and use the space to align the remaining teeth, or align the teeth with arch expansion andpatient to maintain the teeth. In some cases, restore the damaged one. The decision has an esthetic componentalignment of incisors in both arches must be because the lower incisors are visible on smile in older individuals. In this patient, aligning the lower incisors without extraction would alsoconsidered. The key question is whether the require aligning the upper incisors, but this expansion would increasecrowding should be resolved by expanding the arch, lip support and improve the overall facial appearance as well as theremoving some interproximal enamel from each dental appearance. A, Smile before treatment, after loss of one corner of the lower right central incisor. B, Mandibular occlusal view. C, Frontaltooth to provide space,8 or removing one lower view. Note the moderately deep bite and lack of overjet. The restorativeincisor. Expansion of a crowded incisor segment dentist sought orthodontic consultation, thinking that extraction of thecan be done with clear aligners, but if only the damaged tooth might be the best plan. The patient wanted the best esthetic result and accepted a period of treatment with a fixed appliancelower arch is to be treated, the esthetics of the on both arches, after which the incisor would be restored. Theappliance is not a consideration, and a partial fixed orthodontic alignment required 5 months. 0, Mandibular occlusal view after alignment. E, Frontal view. F, Smile after restoration wasappliance is more efficient and cost-effective completed.(Figure 18-21). A segment of A-NiTi wire, withstops to make it slightly advanced, usually is thebest way to bring the teeth into alignment (seeFigure 14-5). FIGURE 14-5 FIGURE 18-21). 637
    • Alignment of Anterior TeethCrowded, Rotated, and Displaced Incisors As arule, spacing is the problem when maxillary incisorsneed realignment to facilitate other treatment.Crowding usually is the problem when alignment of In an adult with a damaged lower incisor (in this case, the left centrallower incisors is considered to provide access for incisor with a crown fracture) and incisor crowding, there are tworestorations, achieve better occlusion, or enable the treatment possibilities: extract the damaged tooth and use the space to align the remaining teeth, or align the teeth with arch expansion andpatient to maintain the teeth. In some cases, restore the damaged one. The decision has an esthetic componentalignment of incisors in both arches must be because the lower incisors are visible on smile in older individuals. Inconsidered. The key question is whether the this patient, aligningupper incisors, but this expansion would increase require aligning the the lower incisors without extraction would alsocrowding should be resolved by expanding the arch, lip support and improve the overall facial appearance as well as theremoving some interproximal enamel from each dental appearance. A, Smile before treatment, after loss of one corner oftooth to provide space,8 or removing one lower the lower right moderately deepB, Mandibular of overjet. The restorative view. Note the central incisor. bite and lack occlusal view. C, Frontalincisor. Expansion of a crowded incisor segment dentist sought orthodontic consultation, thinking that extraction of thecan be done with clear aligners, but if only the damaged tooth might be the best plan. The patient wanted the best esthetic result and accepted a period of treatment with a fixed appliancelower arch is to be treated, the esthetics of the on both arches, after which the incisor would be restored. Theappliance is not a consideration, and a partial fixed orthodontic alignment required 5 months. 0, Mandibular occlusal viewappliance is more efficient and cost-effective after alignment. E, Frontal view. F, Smile after restoration was completed.(Figure 18-21). A segment of A-NiTi of one lower incisor !! No ext. wire, withstops to make it slightly advanced, usually is thebest way to bring the teeth into No braces on upper !! alignment (seeFigure 14-5). Only 5 month tx. time14-5 FIGURE !! FIGURE 18-21). It seems no IPR !! 637
    • Alignment of Anterior TeethCrowded, Rotated, and Displaced Incisors As arule, spacing is the problem when maxillary incisorsneed realignment to facilitate other treatment.Crowding usually is the problem when alignment of In an adult with a damaged lower incisor (in this case, the left centrallower incisors is considered to provide access for incisor with a crown fracture) and incisor crowding, there are tworestorations, achieve better occlusion, or enable the treatment possibilities: extract the damaged tooth and use the space to align the remaining teeth, or align the teeth with arch expansion andpatient to maintain the teeth. In some cases, restore the damaged one. The decision has an esthetic componentalignment of incisors in both arches must be because the lower incisors are visible on smile in older individuals. Inconsidered. The key question is whether the this patient, aligningupper incisors, but this expansion would increase require aligning the the lower incisors without extraction would alsocrowding should be resolved by expanding the arch, lip support and improve the overall facial appearance as well as theremoving some interproximal enamel from each dental appearance. A, Smile before treatment, after loss of one corner oftooth to provide space,8 or removing one lower the lower right moderately deepB, Mandibular of overjet. The restorative view. Note the central incisor. bite and lack occlusal view. C, Frontalincisor. Expansion of a crowded incisor segment dentist sought orthodontic consultation, thinking that extraction of thecan be done with clear aligners, but if only the damaged tooth might be the best plan. The patient wanted the best esthetic result and accepted a period of treatment with a fixed appliancelower arch is to be treated, the esthetics of the on both arches, after which the incisor would be restored. Theappliance is not a consideration, and a partial fixed orthodontic alignment required 5 months. 0, Mandibular occlusal viewappliance is more efficient and cost-effective after alignment. E, Frontal view. F, Smile after restoration was completed.(Figure 18-21). A segment of A-NiTi of one lower incisor !! No ext. wire, with ?stops to make it slightly advanced, usually is thebest way to bring the teeth into No braces on upper !! alignment (seeFigure 14-5). Only 5 month tx. time14-5 FIGURE !! FIGURE 18-21). It seems no IPR !! 637
    • Alignment of Anterior TeethCrowded, Rotated, and Displaced Incisors As arule, spacing is the problem when maxillary incisorsneed realignment to facilitate other treatment.Crowding usually is the problem when alignment of In an adult with a damaged lower incisor (in this case, the left centrallower incisors is considered to provide access for incisor with a crown fracture) and incisor crowding, there are tworestorations, achieve better occlusion, or enable the treatment possibilities: extract the damaged tooth and use the space to align the remaining teeth, or align the teeth with arch expansion andpatient to maintain the teeth. In some cases, restore the damaged one. The decision has an esthetic componentalignment of incisors in both arches must be because the lower incisors are visible on smile in older individuals. Inconsidered. The key question is whether the this patient, aligningupper incisors, but this expansion would increase require aligning the the lower incisors without extraction would alsocrowding should be resolved by expanding the arch, lip support and improve the overall facial appearance as well as theremoving some interproximal enamel from each dental appearance. A, Smile before treatment, after loss of one corner oftooth to provide space,8 or removing one lower the lower right moderately deepB, Mandibular of overjet. The restorative view. Note the central incisor. bite and lack occlusal view. C, Frontalincisor. Expansion of a crowded incisor segment dentist sought orthodontic consultation, thinking that extraction of thecan be done with clear aligners, but if only the damaged tooth might be the best plan. The patient wanted the best esthetic result and accepted a period of treatment with a fixed appliance Crimped stoplower arch is to be treated, the esthetics of the on both arches, after which the incisor would be restored. Theappliance is not a consideration, and a partial fixed orthodontic alignment required 5 months. 0, Mandibular occlusal viewappliance is more efficient and cost-effective after alignment. E, Frontal view. F, Smile after restoration was completed.(Figure 18-21). A segment of A-NiTi wire, withstops to make it slightly advanced, usually is thebest way to bring the teeth into alignment (seeFigure 14-5). FIGURE 14-5).FIGURE 14-5 637
    • Alignment of Anterior TeethCrowded, Rotated, and Displaced Incisors As arule, spacing is the problem when maxillary incisorsneed realignment to facilitate other treatment.Crowding usually is the problem when alignment of In an adult with a damaged lower incisor (in this case, the left centrallower incisors is considered to provide access for incisor with a crown fracture) and incisor crowding, there are tworestorations, achieve better occlusion, or enable the treatment possibilities: extract the damaged tooth and use the space to align the remaining teeth, or align the teeth with arch expansion andpatient to maintain the teeth. In some cases, restore the damaged one. The decision has an esthetic componentalignment of incisors in both arches must be because the lower incisors are visible on smile in older individuals. Inconsidered. The key question is whether the this patient, aligningupper incisors, but this expansion would increase require aligning the the lower incisors without extraction would alsocrowding should be resolved by expanding the arch, lip support and improve the overall facial appearance as well as theremoving some interproximal enamel from each dental appearance. A, Smile before treatment, after loss of one corner oftooth to provide space,8 or removing one lower the lower right moderately deepB, Mandibular of overjet. The restorative view. Note the central incisor. bite and lack occlusal view. C, Frontalincisor. Expansion of a crowded incisor segment dentist sought orthodontic consultation, thinking that extraction of thecan be done with clear aligners, but if only the damaged tooth might be the best plan. The patient wanted the best esthetic result and accepted a period of treatment with a fixed appliancelower arch is to be treated, the esthetics of the on both arches, after which the incisorOpenbecoil first Crimped stop would restored. Theappliance is not a consideration, and a partial fixed orthodontic alignment required 5 months. 0, Mandibular occlusal viewappliance is more efficient and cost-effective after alignment. E, Frontal view. F, Smile after restoration was completed.(Figure 18-21). A segment of A-NiTi wire, withstops to make it slightly advanced, usually is thebest way to bring the teeth into alignment (seeFigure 14-5). FIGURE 14-5).FIGURE 14-5 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexible FIGURE 18-22to be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be the Neither stripping norfinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right lateral incisor extraction shoulda fixed appliance is removed, a canine-to-canine clipretainer, or a bonded fixed retainer. 10 incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C, Mandibular occlusal. The plan was extraction of the primary incisor and be undertaken without a Stripping the contact points of the teeth to remove enamelcan provide space for alignment of mildly irregular lower closure of the extraction site, using a series of Invisalign aligners and bonded attachments to produce the necessary rotation and root movement. diagnostic setup.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After FIGURE 18-22 noted that the maxillary right canine was not eight aligners it was tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9 In severe crowding, removing one lower incisor and using the space to align the other three incisors can produce a satisfactory result and can be managed with clear aligner Alignment of Anterior Teeth therapy if bonded attachments are part of the treatment plan (Figure 18-22). The treatment time and difficulty, whatever the type of appliance, put this at or across the border of comprehensive treatment. Neither stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. Remember that stretched gingival fibers are a potent force for relapse after rotations have been corrected, and that good long-term stability may require a fiberotomy (see Chapter 16). Whether clear aligners or a fixed appliance was used, retention is necessary until restorative or other treatment is completed. This can be the final aligner in a sequence (though this may be too flexible to be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right lateral a fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C, retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners and can provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement. incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard- sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and on undertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called for undesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F, intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used along one lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upper incisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners, managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canine are part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completion time and 18-22FIGURE difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 months at or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.) stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9 In severe crowding, removing one lower incisor and using the space to align the other three incisors can produce a satisfactory result and can be managed with clear aligner Alignment of Anterior Teeth therapy if bonded attachments are part of the treatment plan (Figure 18-22). The treatment time and difficulty, whatever the type of appliance, put this at or across the border of comprehensive treatment. Neither stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. Remember that stretched gingival fibers are a potent force for relapse after rotations have been corrected, and that good long-term stability may require a fiberotomy (see Chapter 16). Whether clear aligners or a fixed appliance was used, retention is necessary until restorative or other treatment is completed. This can be the final aligner in a sequence (though this may be too flexible to be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right lateral a fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C, retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners and can provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement. incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard- sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and on undertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called for undesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F, intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used along one lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upper incisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners, managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canine are part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completion time and 18-22FIGURE difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 months at or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.) stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9 In severe crowding, removing one lower incisor and using the space to align the other three incisors can produce a satisfactory result and can be managed with clear aligner Alignment of Anterior Teeth therapy if bonded attachments are part of the treatment plan (Figure 18-22). The treatment time and difficulty, whatever the type of appliance, put this at or across the border of comprehensive treatment. Neither stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. Remember that stretched gingival fibers are a potent force for relapse after rotations have been corrected, and that good long-term stability may require a fiberotomy (see Chapter 16). Whether clear aligners or a fixed appliance was used, retention is necessary until restorative or other treatment is completed. This can be the final aligner in a sequence (though this may be too flexible to be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right lateral a fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C, retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners and can provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement. incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard- sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and on undertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called for undesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F, intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used along one lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upper incisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners, managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canine are part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completion time and 18-22FIGURE difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 months at or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.) stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce a Inter-arch Tooth Size Discrepancysatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce a Inter-arch Tooth Size Discrepancysatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce a Inter-arch Tooth Size Discrepancysatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce a Inter-arch Tooth Size Discrepancysatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9 In severe crowding, removing one lower incisor and using the space to align the other three incisors can produce a satisfactory result and can be managed with clear aligner Alignment of Anterior Teeth therapy if bonded attachments are part of the treatment plan (Figure 18-22). The treatment time and difficulty, whatever the type of appliance, put this at or across the border of comprehensive treatment. Neither stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. Remember that stretched gingival fibers are a potent force for relapse after rotations have been corrected, and that good long-term stability may require a fiberotomy (see Chapter 16). Whether clear aligners or a fixed appliance was used, retention is necessary until restorative or other treatment is completed. This can be the final aligner in a sequence (though this may be too flexible to be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right lateral a fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C, retainer, or a bonded fixed retainer. 10Dental Dam Stabilizing Cord Stripping the contact points of the teeth to remove enamel can provide space for alignment of mildly irregular lower Mandibular occlusal. The plan was extraction of the primary incisor and closure of the extraction site, using a series of Invisalign aligners and bonded attachments to produce the necessary rotation and root movement.Wedjet® and either aWhaledent, www.coltene.com) Before treatment began, air-rotor stripping of the maxillary the hard- incisors, (Coltè ne fixed appliance or a clear aligner quadrants was done to reduce the tooth-size discrepancy. D, Note posterior sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and on undertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called for undesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F, intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used along one lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upper incisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners, managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canine are part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completion time and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 months at or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.) stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility. 637
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexible Addition or Reduction ?to be a good retainer), a molded thermoplastic retainer aftera fixed appliance is removed, a canine-to-canine clipretainer, or a bonded fixed retainer. 10 This 24-year-old patient had a congenitally missing mandibular right lateral incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C, Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexible Local Treatment or not ?to be a good retainer), a molded thermoplastic retainer aftera fixed appliance is removed, a canine-to-canine clipretainer, or a bonded fixed retainer. 10 This 24-year-old patient had a congenitally missing mandibular right lateral incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C, Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexible Local Treatment or not ?to be a good retainer), a molded thermoplastic retainer aftera fixed appliance is removed, a canine-to-canine clipretainer, or a bonded fixed retainer. 10 This 24-year-old patient had a congenitally missing mandibular right lateral incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C, Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexible Local Treatment or not ?to be a good retainer), a molded thermoplastic retainer aftera fixed appliance is removed, a canine-to-canine clipretainer, or a bonded fixed retainer. 10 This 24-year-old patient had a congenitally missing mandibular right lateral incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C, Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be the 450 530 250 250 280 190 230final aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, 450 475retainer, or a bonded fixed retainer. 10 240 240 270 200 170 Stripping the contact points of the teeth to remove enamel Maxillary occlusal. Note the rotation of the maxillary right canine. C, Mandibular occlusal. The plan was extraction of the primary incisor and closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 months Anchorage Valueat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be the 45 53 25 25 28 19final aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after 23 This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, 45 48retainer, or a bonded fixed retainer. 10 24 24 27 20 17 Stripping the contact points of the teeth to remove enamel Maxillary occlusal. Note the rotation of the maxillary right canine. C, Mandibular occlusal. The plan was extraction of the primary incisor and closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 months Anchorage Valueat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 months Mobile & Non-mobileat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 months Center of Rotationat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 months Apply Bone Screwat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require afiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be Segmental Tech. and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 months Rehearsal on Modelat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingival Ortho.fibers are a potent force for relapse after rotations have beencorrected, and that good long-term stability may require a GPfiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary until (Adjunctive Tx.)restorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called for Implantundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • CHAPTER 18Special Considerations in Treatment for Adults, 623William R. Proffit, David M. SarverAdjunctive vs Comprehensive Treatment, 624 Comprehensive Treatment in Adults,Goals of Adjunctive Treatment, 624 Special Aspects of Orthodontic Therapy for Adults, 637 661Principles of Psychologic Considerations Adjunctive Treatment, 624 Esthetic Appliances in Tx. of Adults TMD as a Reason for Ortho.Adjunctive Treatment Procedures, 627 Applications of Skeletal Anchorage Tx.Comprehensive Treatment in Adults, 637 Retraction and Intrusion of Protruding Incisors Perio. ConsiderationsSpecial Aspects of Orthodontic Therapy for Adults, Finishing and Retention Prostho-implant interactions661
    • Psychologic Considerations A major motivation for orthodontic treatment of youngerpatients is the parents desire to do the best they can for theirchildren. The typical child or adolescent accepts orthodontics inabout the same rather passive way that he or she accepts goingto school, summer camp, and the inevitable junior high schooldance: as just another in the series of events that one mustendure while growing up. Occasionally, of course, anadolescent actively resists orthodontic treatment, and the resultcan be unfortunate for all concerned if the treatment becomesthe focus of an adolescent rebellion. In most instances,however, children tend not to become emotionally involved intheir treatment. Adults in both the younger and older groups,in contrast, seek comprehensive orthodontic treatment becausethey themselves really want it. For the younger group who aretrying to improve their lot in life, exactly what they want is notalways clearly expressed, and some young adults have aremarkably elaborate hidden set of motivations. It is importantto explore why an individual wants treatment and why now asopposed to some other time to avoid setting up a situation inwhich the patients expectations from treatment cannot possiblybe met. Sometimes, orthodontic treatment is sought as a last-ditch effort to improve personal appearance to deal with aseries of complicated social problems. Orthodontic treatmentobviously cannot be relied on to repair personal relationships,save jobs, or overcome a series of financial disasters. If theprospective patient has unrealistic expectations of that sort, it ismuch better to deal with them sooner rather than later. 637
    • Psychologic Considerations A major motivation for orthodontic treatment of younger patients is the parents desire to do the best they can for their children. The typical child or adolescent accepts orthodontics in about the same rather passive way that he or she accepts going to school, summer camp, and the inevitable junior high school dance: as just another in the series of events that one mustFor Adult patients endure while growing up. Occasionally, of course, an adolescent actively resists orthodontic treatment, and the result can be unfortunate for all concerned if the treatment becomes the focus of an adolescent rebellion. In most instances, Why & Why now ? however, children tend not to become emotionally involved in their treatment. Adults in both the younger and older groups, in contrast, seek comprehensive orthodontic treatment because they themselves really want it. For the younger group who are trying to improve their lot in life, exactly what they want is not always clearly expressed, and some young adults have a remarkably elaborate hidden set of motivations. It is important to explore why an individual wants treatment and why now as opposed to some other time to avoid setting up a situation in which the patients expectations from treatment cannot possibly be met. Sometimes, orthodontic treatment is sought as a last- ditch effort to improve personal appearance to deal with a series of complicated social problems. Orthodontic treatment obviously cannot be relied on to repair personal relationships, save jobs, or overcome a series of financial disasters. If the prospective patient has unrealistic expectations of that sort, it is much better to deal with them sooner rather than later. 637
    • Psychologic Considerations A major motivation for orthodontic treatment of younger patients is the parents desire to do the best they can for their children. The typical child or adolescent accepts orthodontics in about the same rather passive way that he or she accepts going to school, summer camp, and the inevitable junior high school dance: as just another in the series of events that one mustFor Adult patients endure while growing up. Occasionally, of course, an adolescent actively resists orthodontic treatment, and the result can be unfortunate for all concerned if the treatment becomes the focus of an adolescent rebellion. In most instances, Why & Why now ? however, children tend not to become emotionally involved in their treatment. Adults in both the younger and older groups, in contrast, seek comprehensive orthodontic treatment because they themselves really want it. For the younger group who are trying to improve their lot in life, exactly what they want is not Unrealistic always clearly expressed, and some young adults have a remarkably elaborate hidden set of motivations. It is important to explore why an individual wants treatment and why now as Expectation? opposed to some other time to avoid setting up a situation in which the patients expectations from treatment cannot possibly be met. Sometimes, orthodontic treatment is sought as a last- ditch effort to improve personal appearance to deal with a series of complicated social problems. Orthodontic treatment obviously cannot be relied on to repair personal relationships, save jobs, or overcome a series of financial disasters. If the prospective patient has unrealistic expectations of that sort, it is much better to deal with them sooner rather than later. 637
    • Psychologic Considerations Most adults in both the younger and older groups, fortunately,understand why they want orthodontics and are realistic aboutwhat they can obtain from it. One might expect those who seektreatment to be less secure and less well-adjusted than theaverage adult, but for the most part, they have a more positiveself-image than average.11 It apparently takes a good deal ofego strength to seek orthodontic treatment as an adult, and egostrength rather than weakness characterizes most potential adultpatients. A patient who seeks treatment primarily because he orshe wants it (internal motivation) is more likely to respond wellpsychologically than a patient whose motivation is the urgingof others or the expected impact of treatment on others(external motivation). External motivation is oftenaccompanied by an increasing impact of the orthodonticproblem on personality (Figure 18-23). Such a patient is likelyto have a complex set of unrecognized expectations fortreatment, the proverbial hidden agenda. One way to identify the minority of individuals who may FIGURE 18-23present problems because of their unrealistic expectations is to Dentofacial deformity can affect an individuals life adjustment. Fortunately, most potential adult orthodontic patients fall into thecompare the patients perception of his or her orthodontic "no problem" category psychologically. Afew highly successfulcondition with the doctors evaluation. If the patient thinks that individuals (who nevertheless may seek treatment) can be thought of as almost overcompensating for their deformity with theirthe appearance or function of the teeth is creating a severe exceptional personability, but they tend to be personable and veryproblem, while an objective assessment simply does not pleasant to work with.For some individuals, however, the orthodontic condition can become the focus for a wide-ranging setcorroborate that, orthodontic treatment should be approached of social adjustment problems that orthodontics alone will not solve. These patients fall into the "inadequate personality" andwith caution. "pathologic personality" categories, who are difficult and almost impossible, respectively, to help. An important aspect of orthodontic diagnosis for adults is understanding where a patient fits along this spectrum. 638
    • Psychologic Considerations Most adults in both the younger and older groups, fortunately,understand why they want orthodontics and are realistic aboutwhat they can obtain from it. One might expect those who seektreatment to be less secure and less well-adjusted than theaverage adult, but for the most part, they have a more positiveself-image than average.11 It apparently takes a good deal ofego strength to seek orthodontic treatment as an adult, and ego Internal Motivationstrength rather than weakness characterizes most potential adultpatients. A patient who seeks treatment primarily because he orshe wants it (internal motivation) is more likely to respond wellpsychologically than a patient whose motivation is the urgingof others or the expected impact of treatment on others(external motivation). External motivation is often External Motivationaccompanied by an increasing impact of the orthodonticproblem on personality (Figure 18-23). Such a patient is likelyto have a complex set of unrecognized expectations fortreatment, the proverbial hidden agenda. One way to identify the minority of individuals who may FIGURE 18-23present problems because of their unrealistic expectations is to Dentofacial deformity can affect an individuals life adjustment. Fortunately, most potential adult orthodontic patients fall into thecompare the patients perception of his or her orthodontic "no problem" category psychologically. Afew highly successfulcondition with the doctors evaluation. If the patient thinks that individuals (who nevertheless may seek treatment) can be thought of as almost overcompensating for their deformity with theirthe appearance or function of the teeth is creating a severe exceptional personability, but they tend to be personable and veryproblem, while an objective assessment simply does not pleasant to work with.For some individuals, however, the orthodontic condition can become the focus for a wide-ranging setcorroborate that, orthodontic treatment should be approached of social adjustment problems that orthodontics alone will not solve. These patients fall into the "inadequate personality" andwith caution. "pathologic personality" categories, who are difficult and almost impossible, respectively, to help. An important aspect of orthodontic diagnosis for adults is understanding where a patient fits along this spectrum. 638
    • Psychologic Considerations Most adults in both the younger and older groups, fortunately,understand why they want orthodontics and are realistic aboutwhat they can obtain from it. One might expect those who seektreatment to be less secure and less well-adjusted than theaverage adult, but for the most part, they have a more positiveself-image than average.11 It apparently takes a good deal ofego strength to seek orthodontic treatment as an adult, and ego Internal Motivationstrength rather than weakness characterizes most potential adultpatients. A patient who seeks treatment primarily because he or I want this? or You want me to doshe wants it (internal motivation) is more likely to respond wellpsychologically than a patient whose motivation is the urgingof others or the expected impact of treatment on others(external motivation). External motivation is often External Motivationaccompanied by an increasing impact of the orthodontic this?problem on personality (Figure 18-23). Such a patient is likelyto have a complex set of unrecognized expectations fortreatment, the proverbial hidden agenda. One way to identify the minority of individuals who may FIGURE 18-23present problems because of their unrealistic expectations is to Dentofacial deformity can affect an individuals life adjustment. Fortunately, most potential adult orthodontic patients fall into thecompare the patients perception of his or her orthodontic "no problem" category psychologically. Afew highly successfulcondition with the doctors evaluation. If the patient thinks that individuals (who nevertheless may seek treatment) can be thought of as almost overcompensating for their deformity with theirthe appearance or function of the teeth is creating a severe exceptional personability, but they tend to be personable and veryproblem, while an objective assessment simply does not pleasant to work with.For some individuals, however, the orthodontic condition can become the focus for a wide-ranging setcorroborate that, orthodontic treatment should be approached of social adjustment problems that orthodontics alone will not solve. These patients fall into the "inadequate personality" andwith caution. "pathologic personality" categories, who are difficult and almost impossible, respectively, to help. An important aspect of orthodontic diagnosis for adults is understanding where a patient fits along this spectrum. 638
    • Dentofacial deformity can affect an individuals life adjustment. Fortunately, most potential adult orthodontic patients fall into the "no problem" category psychologically. A few highly successful individuals (who nevertheless may seek treatment) can be thought of as almost overcompensating for their deformity with their exceptional personability, but they tend to be personable and very pleasant to work with. For some individuals, however, the orthodontic condition can become the focus for a wide-ranging set of social adjustment problems that orthodontics alone will not solve. These patients fall into the "inadequate personality" and "pathologic personality" categories, who are difficult and almost impossible, respectively, to help. An important aspect of orthodontic diagnosis for adults is understanding where a patient fits along thisFIGURE 18-23 spectrum. 638
    • Psychologic Considerations Even highly motivated adults are likely to have some concernabout the appearance of orthodontic appliances. The demandfor an invisible orthodontic appliance comes almost entirelyfrom adults who are concerned about the reaction of others toobvious orthodontic treatment. In an earlier era, this was amajor reason for using removable appliances in adults,particularly the Crozat appliance in the United States. All ofthe possibilities for a better appearing appliance, however, leadto potential compromises in the orthodontic treatment. Plasticbrackets create problems in controlling root position andclosing spaces. Ceramic brackets, though much better,inevitably make treatment more difficult because of theproblems outlined in Chapter 11. Lingual appliances have beengreatly improved since the turn of the twenty-first century andnow make all types of tooth movement quite possible but stillare technically difficult for the doctor to use efficiently and canbe difficult for patients to tolerate. Clear aligners manage sometypes of tooth movement quite well (especially tipping) buthave difficulty with others (especially extrusion, rotation, androot positioning). Small bonded attachments on teeth thatrequire complex movements give the aligner a better purchase, FIGURE 18-22partially overcoming this difficulty (see Figure 18-22). 641
    • Psychologic Considerations Most adults in both the younger and older groups, fortunately,understand why they want orthodontics and are realistic aboutwhat they can obtain from it. One might expect those who seektreatment to be less secure and less well-adjusted than theaverage adult, but for the most part, they have a more positiveself-image than average.11 It apparently takes a good deal ofego strength to seek orthodontic treatment as an adult, and egostrength rather than weakness characterizes most potential adultpatients. A patient who seeks treatment primarily because he orshe wants it (internal motivation) is more likely to respond wellpsychologically than a patient whose motivation is the urgingof others or the expected impact of treatment on others(external motivation). External motivation is oftenaccompanied by an increasing impact of the orthodonticproblem on personality (Figure 18-23). Such a patient is likelyto have a complex set of unrecognized expectations fortreatment, the proverbial hidden agenda. One way to identify the minority of individuals who maypresent problems because of their unrealistic expectations is to Dentofacial deformity can affect an individuals life adjustment. Fortunately, most potential adult orthodontic patients fall into thecompare the patients perception of his or her orthodontic "no problem" category psychologically. Afew highly successfulcondition with the doctors evaluation. If the patient thinks that individuals (who nevertheless may seek treatment) can be thought of as almost overcompensating for their deformity with theirthe appearance or function of the teeth is creating a severe exceptional personability, but they tend to be personable and veryproblem, while an objective assessment simply does not pleasant to work with.For some individuals, however, the orthodontic condition can become the focus for a wide-ranging setcorroborate that, orthodontic treatment should be approached of social adjustment problems that orthodontics alone will not solve. These patients fall into the "inadequate personality" andwith caution. "pathologic personality" categories, who are difficult and almost impossible, respectively, to help. An important aspect of orthodontic diagnosis for adults is understanding where a patient fits along this spectrum. 638
    • on overjet, overbite, posterior intercuspation, and esthetics.9 In severe crowding, removing one lower incisor and using the space to align the other three incisors can produce a satisfactory result and can be managed with clear aligner Psychologic Considerations therapy if bonded attachments are part of the treatment plan (Figure 18-22). The treatment time and difficulty, whatever the type of appliance, put this at or across the border of comprehensive treatment. Neither stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. Remember that stretched gingival fibers are a potent force for relapse after rotations have been corrected, and that good long-term stability may require a fiberotomy (see Chapter 16). Whether clear aligners or a fixed appliance was used, retention is necessary until restorative or other treatment is completed. This can be the final aligner in a sequence (though this may be too flexible to be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right lateral a fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C, retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners and can provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement. incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard- sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and on undertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called for undesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F, intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used along one lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upper incisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners, managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canine are part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completion time and 18-22FIGURE difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 months at or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.) stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. 641
    • on overjet, overbite, posterior intercuspation, and esthetics.9 In severe crowding, removing one lower incisor and using the space to align the other three incisors can produce a satisfactory result and can be managed with clear aligner Psychologic Considerations therapy if bonded attachments are part of the treatment plan (Figure 18-22). The treatment time and difficulty, whatever the type of appliance, put this at or across the border of comprehensive treatment. Neither stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. Remember that stretched gingival fibers are a potent force for relapse after rotations have been corrected, and that good long-term stability may require a fiberotomy (see Chapter 16). Whether clear aligners or a fixed appliance was used, retention is necessary until restorative or other treatment is completed. This can be the final aligner in a sequence (though this may be too flexible to be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right lateral a fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C, retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners and can provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement. incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard- sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and on undertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called for undesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F, intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used along one lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upper incisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners, managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canine are part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completion time and 18-22FIGURE difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 months at or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.) stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. 641
    • on overjet, overbite, posterior intercuspation, and esthetics.9 In severe crowding, removing one lower incisor and using the space to align the other three incisors can produce a satisfactory result and can be managed with clear aligner Psychologic Considerations therapy if bonded attachments are part of the treatment plan (Figure 18-22). The treatment time and difficulty, whatever the type of appliance, put this at or across the border of comprehensive treatment. Neither stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. Remember that stretched gingival fibers are a potent force for relapse after rotations have been corrected, and that good long-term stability may require a fiberotomy (see Chapter 16). Whether clear aligners or a fixed appliance was used, retention is necessary until restorative or other treatment is completed. This can be the final aligner in a sequence (though this may be too flexible to be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right lateral a fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C, retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners and can provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement. incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard- sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and on undertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called for undesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F, intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used along one lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upper incisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners, managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canine are part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completion time and 18-22FIGURE difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 months at or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.) stripping nor incisor extraction should be undertaken without a diagnostic setup to verify feasibility. 641
    • Psychologic Considerations Although there is nothing wrong with using the most estheticappliance possible for an adult patient, the compromises associated withthis approach should be thoroughly discussed in advance. It isunrealistic for a patient to expect that orthodontic treatment can becarried out without other people knowing about it. The whole issue ofthe visibility of the orthodontic appliances is much less important, atleast in the United States, than many patients fear. Orthodontictreatment for adults is certainly socially acceptable, and one does notbecome a victim of discrimination because of visible orthodonticappliances. In a sense, the patients expectations become a self-fulfillingprophecy. If the patient faces others confidently, a visible orthodonticappliance causes no problems. Only if the patient acts ashamed ordefensive is there likely to be any negative reaction from others. Thequestion of whether an orthodontic office should have a separatetreatment area for adults, separated from the adolescents who stillconstitute the bulk of most orthodontic practices, is related to the sameset of negative attitudes. Most comprehensive orthodontic treatment foradolescents is carried out in open treatment areas, not only because theopen area is efficient but also because the learning effect from havingpatients observe what is happening to others is a positive influence inpatient adaptation to treatment. Should adults be segregated into privaterooms, rather than joining the group in the open treatment area? This islogical only if the adult is greatly concerned about privacy (more true ofEuropeans than Americans), or vaguely ashamed of being anorthodontic patient. Sometimes, for some adults, treatment in a privatearea may be preferable, but for most adults, learning from interactingwith other patients helps them understand and tolerate the treatmentprocedures. There are positive advantages in having patients at variousstages of treatment compare their experiences, and this is at least asbeneficial to adults as to children, perhaps more so. 641
    • Psychologic Considerations Although there is nothing wrong with using the most esthetic Open Space ? or Private Space ?appliance possible for an adult patient, the compromises associated withthis approach should be thoroughly discussed in advance. It isunrealistic for a patient to expect that orthodontic treatment can becarried out without other people knowing about it. The whole issue ofthe visibility of the orthodontic appliances is much less important, atleast in the United States, than many patients fear. Orthodontictreatment for adults is certainly socially acceptable, and one does notbecome a victim of discrimination because of visible orthodonticappliances. In a sense, the patients expectations become a self-fulfillingprophecy. If the patient faces others confidently, a visible orthodonticappliance causes no problems. Only if the patient acts ashamed ordefensive is there likely to be any negative reaction from others. Thequestion of whether an orthodontic office should have a separatetreatment area for adults, separated from the adolescents who stillconstitute the bulk of most orthodontic practices, is related to the sameset of negative attitudes. Most comprehensive orthodontic treatment foradolescents is carried out in open treatment areas, not only because theopen area is efficient but also because the learning effect from havingpatients observe what is happening to others is a positive influence inpatient adaptation to treatment. Should adults be segregated into privaterooms, rather than joining the group in the open treatment area? This islogical only if the adult is greatly concerned about privacy (more true ofEuropeans than Americans), or vaguely ashamed of being anorthodontic patient. Sometimes, for some adults, treatment in a privatearea may be preferable, but for most adults, learning from interactingwith other patients helps them understand and tolerate the treatmentprocedures. There are positive advantages in having patients at variousstages of treatment compare their experiences, and this is at least asbeneficial to adults as to children, perhaps more so. 641
    • Psychologic Considerations Although there is nothing wrong with using the most estheticappliance possible for an adult patient, the compromises associated withthis approach should be thoroughly discussed in advance. It isunrealistic for a patient to expect that orthodontic treatment can becarried out without other people knowing about it. The whole issue ofthe visibility of the orthodontic appliances is much less important, atleast in the United States, than many patients fear. Orthodontictreatment for adults is certainly socially acceptable, and one does notbecome a victim of discrimination because of visible orthodonticappliances. In a sense, the patients expectations become a self-fulfillingprophecy. If the patient faces others confidently, a visible orthodonticappliance causes no problems. Only if the patient acts ashamed ordefensive is there likely to be any negative reaction from others. Thequestion of whether an orthodontic office should have a separatetreatment area for adults, separated from the adolescents who stillconstitute the bulk of most orthodontic practices, is related to the sameset of negative attitudes. Most comprehensive orthodontic treatment foradolescents is carried out in open treatment areas, not only because theopen area is efficient but also because the learning effect from havingpatients observe what is happening to others is a positive influence inpatient adaptation to treatment. Should adults be segregated into privaterooms, rather than joining the group in the open treatment area? This islogical only if the adult is greatly concerned about privacy (more true ofEuropeans than Americans), or vaguely ashamed of being anorthodontic patient. Sometimes, for some adults, treatment in a private If the p’t faces other confidently!area may be preferable, but for most adults, learning from interactingwith other patients helps them understand and tolerate the treatment Open space provide p’t to interact with others.procedures. There are positive advantages in having patients at variousstages of treatment compare their experiences, and this is at least asbeneficial to adults as to children, perhaps more so. 641
    • Psychologic Considerations Despite the fact that adults can be treated in the same areaas adolescents, they cannot be handled in exactly the sameway. The typical adolescents passive acceptance of what isbeing done is rarely found in adult patients, who want andexpect a considerable degree of explanation of what ishappening and why. An adult can be counted on to beinterested in the treatment but that does not automaticallytranslate into compliance with instructions. Unless adultsunderstand why they have been asked to do various things,they may choose not to do them, not in the passive way anadolescent might just shrug it off but from an active decisionnot to do it. In addition, adults, as a rule, are less tolerant ofdiscomfort and more likely to complain about pain afteradjustments and about difficulties in speech, eating, andtissue adaptation. Additional chair time to meet thesedemands should be anticipated. These characteristicsmight make adults sound like less desirable orthodonticpatients than adolescents, but this is not necessarily so.Working with individuals who are intensely interested intheir own treatment and motivated to take care of their teethcan be a pleasant and stimulating alternative to the less-involved adolescents. If the expectations of both the doctorand the patient are realistic, comprehensive treatment foradults can be a rewarding experience for both. 641
    • Psychologic Considerations Despite the fact that adults can be treated in the same area as adolescents, they cannot be handled in exactly the same way. The typical adolescents passive acceptance of what isFor Adult patients being done is rarely found in adult patients, who want and expect a considerable degree of explanation of what is happening and why. An adult can be counted on to be interested in the treatment but that does not automatically Explain more ! translate into compliance with instructions. Unless adults understand why they have been asked to do various things, they may choose not to do them, not in the passive way an adolescent might just shrug it off but from an active decision not to do it. In addition, adults, as a rule, are less tolerant ofWhat happen & Why ! discomfort and more likely to complain about pain after adjustments and about difficulties in speech, eating, and tissue adaptation. Additional chair time to meet these demands should be anticipated. These characteristics might make adults sound like less desirable orthodontic patients than adolescents, but this is not necessarily so. Working with individuals who are intensely interested in their own treatment and motivated to take care of their teeth can be a pleasant and stimulating alternative to the less- involved adolescents. If the expectations of both the doctor and the patient are realistic, comprehensive treatment for adults can be a rewarding experience for both. 641
    • Psychologic Considerations Despite the fact that adults can be treated in the same area as adolescents, they cannot be handled in exactly the same way. The typical adolescents passive acceptance of what isFor Adult patients being done is rarely found in adult patients, who want and expect a considerable degree of explanation of what is happening and why. An adult can be counted on to be interested in the treatment but that does not automatically Explain more ! translate into compliance with instructions. Unless adults understand why they have been asked to do various things, they may choose not to do them, not in the passive way an adolescent might just shrug it off but from an active decision not to do it. In addition, adults, as a rule, are less tolerant ofWhat happen & Why ! discomfort and more likely to complain about pain after adjustments and about difficulties in speech, eating, and tissue adaptation. Additional chair time to meet these demands should be anticipated. These characteristics might make adults sound like less desirable orthodonticFight for the same Goal patients than adolescents, but this is not necessarily so. Working with individuals who are intensely interested in their own treatment and motivated to take care of their teeth !! can be a pleasant and stimulating alternative to the less- involved adolescents. If the expectations of both the doctor and the patient are realistic, comprehensive treatment for adults can be a rewarding experience for both. 641
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have been Ortho.corrected, and that good long-term stability may require a Psycho.fiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have been Ortho.corrected, and that good long-term stability may require a Psycho.fiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called for Explain more,undesirable effect on overjet, overbite, posteriorintercuspation, and esthetics.9 In severe crowding, removingone lower incisor and using the space to align the other three 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F, After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used along Make a Positive environment with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • TMD as a Reason for Ortho. Tx. Temporomandibular pain and dysfunction (TMD Ortho. Tx. ✔symptoms) rarely are encountered in children seekingorthodontic treatment, but TMD is a significant motivatingfactor for some adults who consider orthodontic treatment.12The relationship between dental occlusion and TMD is highlycontroversial, and it is important to view this objectively.13Orthodontic treatment can sometimes help patients withTMD, but it cannot be relied on to correct these problems.14Patients need to understand what may happen to theirsymptoms during and after orthodontics. ?Types of Problems In diagnosis of TMD problems, patients are classified asbeing in one of four large groups: masticatory muscledisorders, TM joint disorders, chronic mandibular FIGURE 18-24hypomobility, and growth disorders. 15 From the perspectiveof potential orthodontic treatment in adults, differentiating TMD symptoms arise from two major causes: musclebetween the first two groups is particularly important (Figure spasm and fatigue, which almost always are related to18-24). Because muscle spasm and joint pathology can excessive clenching and grinding in response to stress, andcoexist, the distinction in many patients is difficult. internal joint pathology. As a general guideline, patientsNevertheless, it is unlikely that orthodontics will relieveTMD symptoms in a patient who has internal joint problems with symptoms of muscle spasm and fatigue may be helpedor other nonmuscular sources of pain. Those who have by orthodontic treatment, but simpler methods should bemyofascial pain/dysfunction, on the other hand, may benefit attempted first. Orthodontics alone is rarely useful forfrom improved dental occlusion. patients with internal joint pathology. 642
    • TMD as a Reason for Ortho. Tx. Temporomandibular pain and dysfunction (TMDsymptoms) rarely are encountered in children seekingorthodontic treatment, but TMD is a significant motivatingfactor for some adults who consider orthodontic treatment.12The relationship between dental occlusion and TMD is highlycontroversial, and it is important to view this objectively.13Orthodontic treatment can sometimes help patients withTMD, but it cannot be relied on to correct these problems.14 TMD symptoms:Patients need to understand what may happen to theirsymptoms during and after orthodontics. painTypes of Problems In diagnosis of TMD problems, patients are classified as joint noisebeing in one of four large groups: masticatory muscledisorders, TM joint disorders, chronic mandibular limited openinghypomobility, and growth disorders. 15 From the perspectiveof potential orthodontic treatment in adults, differentiating TMD symptoms arise from two major causes: musclebetween the first two groups is particularly important (Figure spasm and fatigue, which almost always are related to18-24). Because muscle spasm and joint pathology can excessive clenching and grinding in response to stress, andcoexist, the distinction in many patients is difficult. internal joint pathology. As a general guideline, patientsNevertheless, it is unlikely that orthodontics will relieveTMD symptoms in a patient who has internal joint problems with symptoms of muscle spasm and fatigue may be helpedor other nonmuscular sources of pain. Those who have by orthodontic treatment, but simpler methods should bemyofascial pain/dysfunction, on the other hand, may benefit attempted first. Orthodontics alone is rarely useful forfrom improved dental occlusion. patients with internal joint pathology.FIGURE 18-24 642
    • TMD as a Reason for Ortho. Tx. Temporomandibular pain and dysfunction (TMDsymptoms) rarely are encountered in children seekingorthodontic treatment, but TMD is a significant motivatingfactor for some adults who consider orthodontic treatment.12The relationship between dental occlusion and TMD is highlycontroversial, and it is important to view this objectively.13 Muscle spasmOrthodontic treatment can sometimes help patients withTMD, but it cannot be relied on to correct these problems.14 TMD symptoms:Patients need to understand what may happen to their and fatiguesymptoms during and after orthodontics. painTypes of Problems In diagnosis of TMD problems, patients are classified as joint noise Internal jointbeing in one of four large groups: masticatory muscle limited openingdisorders, TM joint disorders, chronic mandibular pathologyhypomobility, and growth disorders. 15 From the perspectiveof potential orthodontic treatment in adults, differentiating TMD symptoms arise from two major causes: musclebetween the first two groups is particularly important (Figure spasm and fatigue, which almost always are related to18-24). Because muscle spasm and joint pathology can excessive clenching and grinding in response to stress, andcoexist, the distinction in many patients is difficult. internal joint pathology. As a general guideline, patientsNevertheless, it is unlikely that orthodontics will relieveTMD symptoms in a patient who has internal joint problems with symptoms of muscle spasm and fatigue may be helpedor other nonmuscular sources of pain. Those who have by orthodontic treatment, but simpler methods should bemyofascial pain/dysfunction, on the other hand, may benefit attempted first. Orthodontics alone is rarely useful forfrom improved dental occlusion. patients with internal joint pathology.FIGURE 18-24 642
    • TMD as a Reason for Ortho. Tx. Temporomandibular pain and dysfunction (TMDsymptoms) rarely are encountered in children seekingorthodontic treatment, but TMD is a significant motivatingfactor for some adults who consider orthodontic treatment.12The relationship between dental occlusion and TMD is highlycontroversial, and it is important to view this objectively.13 Clenching, grinding Muscle spasmOrthodontic treatment can sometimes help patients withTMD, but it cannot be relied on to correct these problems.14 TMD symptoms: (stress response)Patients need to understand what may happen to their and fatiguesymptoms during and after orthodontics. painTypes of Problems In diagnosis of TMD problems, patients are classified as joint noise Internal jointbeing in one of four large groups: masticatory muscle limited openingdisorders, TM joint disorders, chronic mandibular pathologyhypomobility, and growth disorders. 15 From the perspectiveof potential orthodontic treatment in adults, differentiating TMD symptoms arise from two major causes: musclebetween the first two groups is particularly important (Figure spasm and fatigue, which almost always are related to18-24). Because muscle spasm and joint pathology can excessive clenching and grinding in response to stress, andcoexist, the distinction in many patients is difficult. internal joint pathology. As a general guideline, patientsNevertheless, it is unlikely that orthodontics will relieveTMD symptoms in a patient who has internal joint problems with symptoms of muscle spasm and fatigue may be helpedor other nonmuscular sources of pain. Those who have by orthodontic treatment, but simpler methods should bemyofascial pain/dysfunction, on the other hand, may benefit attempted first. Orthodontics alone is rarely useful forfrom improved dental occlusion. patients with internal joint pathology.FIGURE 18-24 642
    • TMD as a Reason for Ortho. Tx. Temporomandibular pain and dysfunction (TMDsymptoms) rarely are encountered in children seekingorthodontic treatment, but TMD is a significant motivatingfactor for some adults who consider orthodontic treatment.12The relationship between dental occlusion and TMD is highlycontroversial, and it is important to view this objectively.13 Clenching, grinding Muscle spasmOrthodontic treatment can sometimes help patients withTMD, but it cannot be relied on to correct these problems.14 TMD symptoms: (stress response)Patients need to understand what may happen to their and fatiguesymptoms during and after orthodontics. painTypes of Problems In diagnosis of TMD problems, patients are classified as joint noise Internal jointbeing in one of four large groups: masticatory muscle limited openingdisorders, TM joint disorders, chronic mandibular pathologyhypomobility, and growth disorders. 15 From the perspectiveof potential orthodontic treatment in adults, differentiating TMD symptoms arise from two major causes: musclebetween the first two groups is particularly important (Figure spasm and fatigue, which almost always are related to18-24). Because muscle spasm and joint pathology can excessive clenching and grinding in response to stress, andcoexist, the distinction in many patients is difficult. internal joint pathology. As a general guideline, patientsNevertheless, it is unlikely that orthodontics will relieveTMD symptoms in a patient who has internal joint problems with symptoms of muscle spasm and fatigue may be helpedor other nonmuscular sources of pain. Those who have by orthodontic treatment, but simpler methods should bemyofascial pain/dysfunction, on the other hand, may benefit attempted first. Orthodontics alone is rarely useful forfrom improved dental occlusion. patients with internal joint pathology.FIGURE 18-24 642
    • TMD as a Reason for Ortho. Tx. Temporomandibular pain and dysfunction (TMDsymptoms) rarely are encountered in children seekingorthodontic treatment, but TMD is a significant motivatingfactor for some adults who consider orthodontic treatment.12The relationship between dental occlusion and TMD is highlycontroversial, and it is important to view this objectively.13 Clenching, grinding Muscle spasmOrthodontic treatment can sometimes help patients withTMD, but it cannot be relied on to correct these problems.14 TMD symptoms: (stress response)Patients need to understand what may happen to their and fatiguesymptoms during and after orthodontics. painTypes of Problems In diagnosis of TMD problems, patients are classified as joint noise Internal jointbeing in one of four large groups: masticatory muscle limited openingdisorders, TM joint disorders, chronic mandibular pathologyhypomobility, and growth disorders. 15 From the perspectiveof potential orthodontic treatment in adults, differentiating TMD symptoms arise from two major causes: musclebetween the first two groups is particularly important (Figure18-24). Because muscle spasm and joint pathology can Ortho. Tx. spasm and fatigue, which almost always are related to excessive clenching and grinding in response to stress, andcoexist, the distinction in many patients is difficult. internal joint pathology. As a general guideline, patientsNevertheless, it is unlikely that orthodontics will relieveTMD symptoms in a patient who has internal joint problems with symptoms of muscle spasm and fatigue may be helpedor other nonmuscular sources of pain. Those who have by orthodontic treatment, but simpler methods should bemyofascial pain/dysfunction, on the other hand, may benefit attempted first. Orthodontics alone is rarely useful forfrom improved dental occlusion. patients with internal joint pathology.FIGURE 18-24 642
    • TMD as a Reason for Ortho. Tx. Temporomandibular pain and dysfunction (TMDsymptoms) rarely are encountered in children seekingorthodontic treatment, but TMD is a significant motivatingfactor for some adults who consider orthodontic treatment.12The relationship between dental occlusion and TMD is highlycontroversial, and it is important to view this objectively.13 Clenching, grinding Muscle spasmOrthodontic treatment can sometimes help patients withTMD, but it cannot be relied on to correct these problems.14 TMD symptoms: (stress response)Patients need to understand what may happen to their and fatiguesymptoms during and after orthodontics. painTypes of Problems In diagnosis of TMD problems, patients are classified as ✔ joint noise Internal jointbeing in one of four large groups: masticatory muscle limited openingdisorders, TM joint disorders, chronic mandibular pathologyhypomobility, and growth disorders. 15 From the perspectiveof potential orthodontic treatment in adults, differentiating TMD symptoms arise from two major causes: musclebetween the first two groups is particularly important (Figure18-24). Because muscle spasm and joint pathology can Ortho. Tx. spasm and fatigue, which almost always are related to excessive clenching and grinding in response to stress, andcoexist, the distinction in many patients is difficult. internal joint pathology. As a general guideline, patientsNevertheless, it is unlikely that orthodontics will relieveTMD symptoms in a patient who has internal joint problems with symptoms of muscle spasm and fatigue may be helpedor other nonmuscular sources of pain. Those who have by orthodontic treatment, but simpler methods should bemyofascial pain/dysfunction, on the other hand, may benefit attempted first. Orthodontics alone is rarely useful forfrom improved dental occlusion. patients with internal joint pathology.FIGURE 18-24 642
    • TMD as a Reason for Ortho. Tx. Temporomandibular pain and dysfunction (TMDsymptoms) rarely are encountered in children seekingorthodontic treatment, but TMD is a significant motivatingfactor for some adults who consider orthodontic treatment.12The relationship between dental occlusion and TMD is highlycontroversial, and it is important to view this objectively.13 Clenching, grinding Muscle spasmOrthodontic treatment can sometimes help patients withTMD, but it cannot be relied on to correct these problems.14 TMD symptoms: (stress response)Patients need to understand what may happen to their and fatiguesymptoms during and after orthodontics. painTypes of Problems In diagnosis of TMD problems, patients are classified as ✔ joint noise Internal jointbeing in one of four large groups: masticatory muscle limited openingdisorders, TM joint disorders, chronic mandibular pathologyhypomobility, and growth disorders. 15 From the perspective ?of potential orthodontic treatment in adults, differentiating TMD symptoms arise from two major causes: musclebetween the first two groups is particularly important (Figure18-24). Because muscle spasm and joint pathology can Ortho. Tx. spasm and fatigue, which almost always are related to excessive clenching and grinding in response to stress, andcoexist, the distinction in many patients is difficult. internal joint pathology. As a general guideline, patientsNevertheless, it is unlikely that orthodontics will relieveTMD symptoms in a patient who has internal joint problems with symptoms of muscle spasm and fatigue may be helpedor other nonmuscular sources of pain. Those who have by orthodontic treatment, but simpler methods should bemyofascial pain/dysfunction, on the other hand, may benefit attempted first. Orthodontics alone is rarely useful forfrom improved dental occlusion. patients with internal joint pathology.FIGURE 18-24 642
    • TMD as a Reason for Ortho. Tx.Types of Problems FIGURE 18-25 Almost all of us develop some symptoms of Three radiographic views of arthritic degeneration of a left mandibulardegenerative joint disease as we grow older, and it is not condyle, from CBCT images. Note the flattening of the condylar head andsurprising that the jaw joints sometimes are involved the lipping posteriorly, which can be visualized in a view similar to what is(Figure 18-25). Arthritic involvement of the TM joints is seen in a panoramic radiograph (A) but are seen more clearly in the imagesmost likely to be the cause of TMD symptoms in patients that show the condylar area (B and C). With CBCT images it is possible to rotate the field of view as desired.who have arthritic changes in other joints of the body. Acomponent of muscle spasm and muscle pain should besuspected in individuals whose only symptoms are in theTM joint area, even if radiographs show moderate arthriticdegeneration of the joint. Displacement of the disk (Figure 18-26) can arisefrom a number of causes. One possibility is trauma to thejoint, so that the ligaments that oppose the action of thelateral pterygoid muscle are stretched or torn. In this FIGURE 18-26circumstance, muscle contraction moves the disk forwardas the mandibular condyles translate forward on wideopening, but the ligaments do not restore the disk to itsproper position when the jaw is closed. The result is a A, Computed tomography (CT) view of a displaced mandibular disk,click upon opening and closing, as the disk pops into place which can be visualized (as a darker area) in front of the condyle. B, Magnetic resonance imaging (MRI) view of a displaced disk, with the anterior andover the condylar head as the patient opens, but is posterior bands indicated on the adjacent sketch. There is evidence on thisdisplaced anteriorly on closure. scan of a regenerating disk, as shown in the dashed area. MRI scans have largely replaced radiographic views for the diagnosis of disk displacement because the soft tissues can be seen more clearly and no ionizing radiation is required, while cone-beam CT (CBCT) is preferred for visualization of bony changes. 642
    • CTFIGURE 18-25 642
    • CT 3D condylar morphologyFIGURE 18-25 642
    • MRI Soft tissue conditionFIGURE 18-26 642
    • Figure 4a. Morphologic features of the normal disk. Tomas X et al. Radiographics 2006;26:765-781©2006 by Radiological Society of North America
    • TMD as a Reason for Ortho. Tx.Types of Problems The click and symptoms associated with it can be corrected if It is possible to demonstrate that some types of occlusalan occlusal splint is used to prevent the patient from closing discrepancies predispose patients who clench or grind their teethbeyond the point at which displacement occurs. The resulting to the development of TMD symptoms. It must be kept in mind,relief of pain influences patients and dentists to seek either however, that it takes two factors to produce myofascial pain: anrestorative or orthodontic treatment to increase facial vertical occlusal discrepancy and a patient who clenches or grinds thedimension. However, orthodontic elongation of all posterior teeth. Perhaps the most compelling argument againstteeth to control disk displacement is not a treatment procedure malocclusion as a primary cause of TMD is the observation thatthat should be undertaken lightly. Often, the patient whose TMD is no more prevalent in patients with severe malocclusionsymptoms have been controlled by a splint can tolerate its than in the general population.16 The dictum "let your teethreduction or removal, without requiring major occlusal changes. alone" would solve myofascial pain problems if it could beAs a general rule, there are better ways of handling disk followed by the patient.displacement than orthodontic treatment. Myofascial paindevelops when muscles are overly fatigued and tend to go intospasm. It is all but impossible to overwork the jaw muscles tothis extent during normal eating and chewing. To producemyofascial pain, the patient must be clenching or grinding theteeth for many hours per day, presumably as a response to,stress. Great variations are seen in the way different individualsrespond to stress, both in the organ system that feels the strain(many problems besides TMD are related to stress) and in theamount of stress that can be tolerated before symptoms appear(tense individuals develop stress-related symptoms before theirrelaxed colleagues do). For this reason, it is impossible to saythat occlusal discrepancies of any given degree will lead toTMD symptoms. 642
    • TMD as a Reason for Ortho. Tx.Types of Problems The click and symptoms associated with it can be corrected if It is possible to demonstrate that some types of occlusal TMD is no more prevalent in p’t withan occlusal splint is used to prevent the patient from closingbeyond the point at which displacement occurs. The resultingrelief of pain influences patients and dentists to seek either discrepancies predispose patients who clench or grind their teeth to the development of TMD symptoms. It must be kept in mind, however, that it takes two factors to produce myofascial pain: an severe malocclusionrestorative or orthodontic treatment to increase facial verticaldimension. However, orthodontic elongation of all posteriorteeth to control disk displacement is not a treatment procedure occlusal discrepancy and a patient who clenches or grinds the teeth. Perhaps the most compelling argument against malocclusion as a primary cause of TMD is the observation thatthat should be undertaken lightly. Often, the patient whose TMD is no more prevalent in patients with severe malocclusionsymptoms have been controlled by a splint can tolerate its than in the general population.16 The dictum "let your teethreduction or removal, without requiring major occlusal changes. alone" would solve myofascial pain problems if it could beAs a general rule, there are better ways of handling disk followed by the patient.displacement than orthodontic treatment. Myofascial paindevelops when muscles are overly fatigued and tend to go intospasm. It is all but impossible to overwork the jaw muscles tothis extent during normal eating and chewing. To producemyofascial pain, the patient must be clenching or grinding theteeth for many hours per day, presumably as a response to,stress. Great variations are seen in the way different individualsrespond to stress, both in the organ system that feels the strain(many problems besides TMD are related to stress) and in theamount of stress that can be tolerated before symptoms appear(tense individuals develop stress-related symptoms before theirrelaxed colleagues do). For this reason, it is impossible to saythat occlusal discrepancies of any given degree will lead toTMD symptoms. 642
    • TMD as a Reason for Ortho. Tx.Types of Problems The click and symptoms associated with it can be corrected if It is possible to demonstrate that some types of occlusal TMD is no more prevalent in p’t withan occlusal splint is used to prevent the patient from closingbeyond the point at which displacement occurs. The resultingrelief of pain influences patients and dentists to seek either discrepancies predispose patients who clench or grind their teeth to the development of TMD symptoms. It must be kept in mind, however, that it takes two factors to produce myofascial pain: an severe malocclusionrestorative or orthodontic treatment to increase facial verticaldimension. However, orthodontic elongation of all posteriorteeth to control disk displacement is not a treatment procedure occlusal discrepancy and a patient who clenches or grinds the teeth. Perhaps the most compelling argument against malocclusion as a primary cause of TMD is the observation thatthat should be undertaken lightly. Often, the patient whose TMD is no more prevalent in patients with severe malocclusion Diagnosis TMD before Ortho. treatmentsymptoms have been controlled by a splint can tolerate its than in the general population.16 The dictum "let your teethreduction or removal, without requiring major occlusal changes. alone" would solve myofascial pain problems if it could beAs a general rule, there are better ways of handling disk followed by the patient.displacement than orthodontic treatment. Myofascial paindevelops when muscles are overly fatigued and tend to go intospasm. It is all but impossible to overwork the jaw muscles tothis extent during normal eating and chewing. To producemyofascial pain, the patient must be clenching or grinding theteeth for many hours per day, presumably as a response to,stress. Great variations are seen in the way different individualsrespond to stress, both in the organ system that feels the strain(many problems besides TMD are related to stress) and in theamount of stress that can be tolerated before symptoms appear(tense individuals develop stress-related symptoms before theirrelaxed colleagues do). For this reason, it is impossible to saythat occlusal discrepancies of any given degree will lead toTMD symptoms. 642
    • Clenching, grinding Muscle spasm TMD symptoms: (stress response) and fatigue pain joint noise Internal joint limited opening pathologyFIGURE 18-24 642
    • Occlusal discrepancy Clenching, grinding Muscle spasm TMD symptoms: (stress response) and fatigue pain joint noise Internal joint limited opening pathologyFIGURE 18-24 642
    • Ortho. Tx. Occlusal discrepancy Clenching, grinding Muscle spasm TMD symptoms: (stress response) and fatigue pain joint noise Internal joint limited opening pathologyFIGURE 18-24 642
    • + Ortho. Tx. Occlusal discrepancy Clenching, grinding Muscle spasm TMD symptoms: (stress response) and fatigue pain joint noise Internal joint limited opening pathologyFIGURE 18-24 642
    • + Ortho. Tx. Occlusal +/- discrepancy Clenching, grinding Muscle spasm TMD symptoms: (stress response) and fatigue pain joint noise Internal joint limited opening pathologyFIGURE 18-24 642
    • + Ortho. Tx. Occlusal +/- discrepancy Clenching, grinding Muscle spasm TMD symptoms: (stress response) and fatigue pain joint noise Internal joint limited opening pathologyFIGURE 18-24 Occlusal splint 642
    • + Ortho. Tx. Occlusal +/- discrepancy Clenching, grinding Muscle spasm TMD symptoms: (stress response) and fatigue pain joint noise Internal joint limited opening pathology +/- +/- +/-FIGURE 18-24 Occlusal splint 642
    • + Ortho. Tx. Occlusal +/- discrepancyClenching, grinding Muscle spasm TMD symptoms: (stress response) and fatigue pain joint noise Internal joint limited opening pathology +/- +/- +/-Stress release Occlusal splint IDT 642
    • TMD as a Reason for Ortho. Tx.Treatmentperspective, three broad approaches to myofascial pain From this Indicationssymptoms can be considered: reducing the amount of stress;reducing the patients reactions to stress; or improving the occlusion,thereby making it harder for patients to hurt themselves. Drasticalteration of the occlusion, by either restorative dental procedures ororthodontics, is logical only if the less invasive stress-control andstress-adaptation approaches have failed. In that circumstance,orthodontic treatment to alter the occlusion so that the patient canbetter tolerate parafunctional activity may be worth attempting. Insome instances, this may involve orthognathic surgery to repositionthe jaws. The extent to which TMD symptoms in many adults disappearwhen comprehensive orthodontic treatment begins can be surprisingand overly gratifying to those who do not understand the etiology ofmyofascial pain. Orthodontic intervention can appear almost magicalin the way that TMD symptoms disappear long before the occlusalrelationships have been corrected. The explanation is simple-orthodontic treatment makes the teeth sore, so grinding or clenchingsensitive teeth as a means of handling stress does not produce thesame subconscious gratification as previously; the parafunctionalactivity stops; and the symptoms vanish. The changing occlusalrelationships also contribute to breaking up the habit patterns thatcontributed to the muscle fatigue and pain. The same benefit occurswith orthognathic surgery. No matter what the type of orthodontictreatment, symptoms are unlikely to be present while movement of asignificant number of teeth is occurring, as long as treatment thatproduces strongly deflective contacts is avoided. Prolonged use of Stress releaseClass II or Class III elastics may not be well tolerated in adults whohave had TMD problems and should be avoided (for that matter,prolonged use of elastics should be avoided in most other adultpatients as well). 643
    • TMD as a Reason for Ortho. Tx.Treatmentperspective, three broad approaches to myofascial pain From this Indicationssymptoms can be considered: reducing the amount of stress;reducing the patients reactions to stress; or improving the occlusion,thereby making it harder for patients to hurt themselves. Drasticalteration of the occlusion, by either restorative dental procedures ororthodontics, is logical only if the less invasive stress-control andstress-adaptation approaches have failed. In that circumstance, Amount of Stressorthodontic treatment to alter the occlusion so that the patient canbetter tolerate parafunctional activity may be worth attempting. Insome instances, this may involve orthognathic surgery to repositionthe jaws. The extent to which TMD symptoms in many adults disappearwhen comprehensive orthodontic treatment begins can be surprising Reaction to Stressand overly gratifying to those who do not understand the etiology ofmyofascial pain. Orthodontic intervention can appear almost magicalin the way that TMD symptoms disappear long before the occlusalrelationships have been corrected. The explanation is simple-orthodontic treatment makes the teeth sore, so grinding or clenchingsensitive teeth as a means of handling stress does not produce thesame subconscious gratification as previously; the parafunctionalOcclusal Discrepancyactivity stops; and the symptoms vanish. The changing occlusalrelationships also contribute to breaking up the habit patterns thatcontributed to the muscle fatigue and pain. The same benefit occurswith orthognathic surgery. No matter what the type of orthodontictreatment, symptoms are unlikely to be present while movement of asignificant number of teeth is occurring, as long as treatment thatproduces strongly deflective contacts is avoided. Prolonged use ofClass II or Class III elastics may not be well tolerated in adults whohave had TMD problems and should be avoided (for that matter,prolonged use of elastics should be avoided in most other adultpatients as well). 643
    • TMD as a Reason for Ortho. Tx. Treatment Indications The moment of truth for TMD patients who have had orthodontic treatment comes some time after the orthodontics is completed, when the clenching and grinding that originally caused the problem tend to recur. At that point, even if the occlusal relationships have been significantly improved, it may be impossible to keep the patient from moving into extreme jaw positions and engaging in parafunctional activity that produces pain. The use of interocclusal splints in this situation may be the only way to keep symptoms from recurring. In short, the miraculous cure that orthodontic treatment often provides for myofascial pain tends to disappear with the appliance. Those who have had symptoms in the past are always at risk of having them recur. Occasionally, orthodontic treatment is made more complicated by previous splint therapy for TMD problems. If an occlusal splint for TMD symptoms covers the posterior but not the anterior teeth, the anterior teeth that have been taken out of occlusion begin to erupt again and may come back into occlusion even though the posterior teeth are still separated (Figure 18-27). Clinically, it may appear that the posterior teeth are being intruded, but incisor eruption usually is a greater contributor to Occlusal relationships in a 24-year-old woman who had the development of posterior open bite. In only a few months, the worn a splint covering only her posterior teeth for the previous patient may end up in a situation in which discarding the splint 18 months. Note the posterior open bite when the splint was has become impossible. Then the only treatment possibilities are taken out. This was created by a combination of intrusion of elongation of the posterior teeth, either with crowns or the posterior teeth and further eruption of the anterior teeth.FIGURE 18-27 orthodontic extrusion, or intrusion of the anterior teeth. Discarding the splint had become impossible. 644
    • TMD as a Reason for Ortho. Tx.Treatment Indications Orthodontic intervention at this stage is difficult because TMD symptoms are likely to develop immediately if the splint is removed, and it is not possible to elongate the posterior teeth orthodontically without discarding or cutting down the splint. Placing orthodontic attachments on the posterior teeth and using light vertical elastics to the posterior segments can be used to bring the posterior teeth back into occlusion (Figure 18-28), if the patient can tolerate this treatment. Some re-intrusion of the elongated anterior teeth is likely to occur, but a significant increase in face height is often maintained. Although permanently increasing the vertical dimension to control disk displacement can be accomplished in this way, this treatment plan should be used withFIGURE 18-28 extreme caution. 644
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have been Ortho.corrected, and that good long-term stability may require a TMDfiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F,intercuspation, and esthetics.9 In severe crowding, removing After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used alongone lower incisor and using the space to align the other three with the aligner to further rotate it. New records were taken, and four upperincisors can produce a satisfactory result and can be and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.
    • on overjet, overbite, posterior intercuspation, and esthetics.9In severe crowding, removing one lower incisor and usingthe space to align the other three incisors can produce asatisfactory result and can be managed with clear alignerAlignment of Anterior Teeththerapy if bonded attachments are part of the treatment plan(Figure 18-22). The treatment time and difficulty, whateverthe type of appliance, put this at or across the border ofcomprehensive treatment. Neither stripping nor incisorextraction should be undertaken without a diagnostic setupto verify feasibility. Remember that stretched gingivalfibers are a potent force for relapse after rotations have been Ortho.corrected, and that good long-term stability may require a TMDfiberotomy (see Chapter 16). Whether clear aligners or afixed appliance was used, retention is necessary untilrestorative or other treatment is completed. This can be thefinal aligner in a sequence (though this may be too flexibleto be a good retainer), a molded thermoplastic retainer after This 24-year-old patient had a congenitally missing mandibular right laterala fixed appliance is removed, a canine-to-canine clip incisor and a retained but failing primary incisor. A, Frontal view. B, Maxillary occlusal. Note the rotation of the maxillary right canine. C,retainer, or a bonded fixed retainer. 10 Mandibular occlusal. The plan was extraction of the primary incisor and Stripping the contact points of the teeth to remove enamel closure of the extraction site, using a series of Invisalign aligners andcan provide space for alignment of mildly irregular lower bonded attachments to produce the necessary rotation and root movement.incisors, and either a fixed appliance or a clear aligner Before treatment began, air-rotor stripping of the maxillary posterior quadrants was done to reduce the tooth-size discrepancy. D, Note the hard-sequence can provide the tooth movement. This should be to-see bonded attachments on the maxillary right canine and incisors and onundertaken with caution, however, because it may have an the mandibular right canine and central incisor. The original plan called forundesirable effect on overjet, overbite, posterior 13 upper and 15 lower aligners, plus three overcorrection aligners. E and F, Take care TMD before Ortho. Tx.intercuspation, and esthetics.9 In severe crowding, removingone lower incisor and using the space to align the other threeincisors can produce a satisfactory result and can be After eight aligners it was noted that the maxillary right canine was not tracking, and an elastic to additional bonded attachments was used along with the aligner to further rotate it. New records were taken, and four upper and five lower revision aligners, with three revision overcorrection aligners,managed with clear aligner therapy if bonded attachments were fabricated. G to I, Completion of treatment. A bonded canine-to-canineare part of the treatment plan (Figure 18-22). The treatment mandibular retainer was used, and the final maxillary aligner was continued at night as the maxillary retainer. J, Panoramic radiograph at the completiontime and difficulty, whatever the type of appliance, put this of treatment. Total treatment time was 19 months (which included 2 monthsat or across the border of comprehensive treatment. Neither waiting for revision aligners). (Courtesy Dr. W. Gierie.)stripping nor incisor extraction should be undertakenwithout a diagnostic setup to verify feasibility.