Invisible Orthodontics Posts

21/01/15
Invisible Orthodontics: a case report of severe open bite
Anna Mariniello

29/05/13
Invisible orthodontics: ectopic buccal canine malocclusion
Anna Mariniello

17/01/13
Lingual Orthodontics without brackets for the treatment of Angle II Class malocclusions
Anna Mariniello Fabio Cozzolino

22/03/11
Restoration of a lower incisor periodontal health by means of a selected radicular torque control using a fixed lingual orthodontic: case report
Matteo Beretta Nunzio Cirulli Aldo Macchi

01/10/10
Active retainers clinical procedure
Anna Mariniello Fabio Cozzolino

17/06/10
Invisible Orthodontics: Class I malocclusion with impacted canine and deep bite
Anna Mariniello Fabio Cozzolino

07/09/09
Invisible Orthodontics: lingual Orthodontics without brackets
Anna Mariniello

30/06/09
Lingual Orthodontics
Anna Mariniello

29/05/09
Lingual Orthodontics without brackets: Active Retainers
Anna Mariniello

10/04/09
Fixed Active Retainer (MAC): Lingual Orthodontics using active retainers
Aldo Macchi Nunzio Cirulli

29/03/09
Invisible Orthodontics: Diastema closure
Anna Mariniello Fabio Cozzolino

17/03/09
Active retainers to solve anterior misalignments: an innovative Lingual Orthodontic method without brackets
Anna Mariniello

19/01/09
Invisible Orthodontics
Anna Mariniello Fabio Cozzolino Giuseppe Cozzolino

04/12/08
Invisible Orthodontics against Esthetic Orthodontics: Lingual Orthodontics without brackets through the use of pre-activated retainers
Anna Mariniello Giuseppe Cozzolino Fabio Cozzolino

18/11/08
Micro-screws in Orthodontics – clinical problems
Fabio Cozzolino Anna Mariniello

04/11/08
Invisible Orthodontics: reduction of lower arch crowding by means of the pre-actived retainers
Anna Mariniello


Invisible Orthodontics: a case report of severe open bite

Invisible Orthodontics: a case report of severe open bite

 

‪Many adult patients require aligned teeth to improve their aesthetics, as dental exposure and smile are fundamental for the beauty of the face.

For this reason, the orthodontic treatment plan is the result of a careful radiographic examination and related cephalometric tracing, a detailed examination of the dental casts and related space analysis, but also an accurate aesthetic facial analysis.

We want to focus our attention on the exposure of the maxillary incisors with lips at rest. This is critical, for example, when we treat a case with overbite alterations, both in excess and in defect.

The clinical case we introduce is an example of treatment in case of anterior open bite. The patient asked for a fixed invisible lingual orthodontic therapy without brackets, to completely hide the presence of the device without phonetic distortions and tongue irritations.

Ortopantomography, Latero-Lateral Teleradiography, cephalometric study, cephalometric values chart :

Invisible orthodontics: ectopic buccal canine malocclusion

Invisible orthodontics: ectopic buccal canine malocclusion

 

Bracketless invisible orthodontics is a new orthodontic device to treat malocclusion, based on the use of thin wires directly bonded on invisible teeth surfaces.

Such appliance is not visible but also well comfortable for the tongue and soft tissues, thanks to the extremely personalized and anatomical modelling, and takes less space than the lingual brackets.

So it represents a possible therapeutic alternative to propose to all those patients that need an invisible and painless treatment.

The application field goes to the simple levelling therapies to the more complex, who need for example teeth extractions and bodily teeth movement. The association to miniscrews can be very useful, as it also occurs in the classical brackets therapy.

The case that we propose is an extractive treatment with a dental and a skeletal anchorage.

The patient, came to our attention, had a malocclusion characterized by:

  • first class molar and canine on the right
  • second class molar on the left
  • complete absence of space for the left ectopic buccal canine;
  • upper and lower teeth crowding
  • upper midline shifted 2,5 mm to the left
  • Overbite of 1 mm for 12, 3 mm for 11 and 21, 0 mm for 22.
  • Overjet of 2,5 mm for 12, 2 mm for 11 and 21, 0 mm for 22.

 

1 canino ortodonzia sovradente

Lingual Orthodontics without brackets for the treatment of Angle II Class malocclusions

Lingual Orthodontics without brackets for the treatment of Angle II Class malocclusions

Fixed orthodontics is the elected treatment in any age permanent dentition patients.

In fact, in most of cases only with a fixed appliance is possible to achieve a precise and controlled dental movement.

When patient needs an invisible treatment the answer is a fixed lingual treatment, that could be realized with or without brackets. The appliance is so bonded on the lingual aspect and this is why it is not visible.

At first lingual fixed orthodontic without brackets was deviced to solve relapse of previous classic brackets treatment that didn’t want anymore a brackets therapy. Then was applied to treat malocclusion in patients never treated before because it does not produce tongue and soft tissues pains and phonetics diseases that usually occurred with a lingual brackets therapy.

With fixed lingual orthodontic without brackets it is possible to treat every kind of malocclusions by means of orthodontic wires directly bonded on the lingual aspect of the teeth, like the active retainers, but also other devices, like the mini-screws. Mini-screws are a recent innovation in orthodontic treatment and have a large application also in conventional brackets therapy, because they allowed a maximum skeletal anchorage and a faster dental movement.

The following clinical case is an example of dental and skeletal second class treated by means of this innovative therapy.

The patients, a 25 years old female, presented at a clinical examination (fig. 1-6)

  • an edge to edge molar and canine and a scissor bite between 24-34 on the left side
  • an edge to edge canine and a previous extraction of tooth 46 with mesialization and inclination of tooth 47 on the right side

angle II class malocclusion

Restoration of a lower incisor periodontal health by means of a selected radicular torque control using a fixed lingual orthodontic: case report

Restoration of a lower incisor periodontal health by means of a selected radicular torque control using a fixed lingual orthodontic: case report

 

A 25 years old girl previously treated with a fixed orthodontic appliance, has come to the chairside examination becouse of the gum vestibular resorption on tooth 41, with a sensibility increase and the diffucult to keep a good domiciliar oral igyene.

The clinical exam showed a severe gum resorption of this tooth with a buccal movement of the rooth and a traumatic contact with the antagonist because of the extrusion.

There was also a fixed contention in the lower arch from 3.2 to 4.2 that was damaged and repaired a lot of time and because of an inadeguate bonding procedure has became an active retainer. This exerted a couple of forces that generated an incontrolled radicular buccal torque of tooth 4.1.

The treatment provided the removal of the old retainer, a professional oral hygiene and the application of a fixed lingual appliance by means of self ligating i-TT? brackets from 3.4 to 4.4. The purpose was to levell teeth, to remove the traumatic contact, to correct the radicular torque of 4.1 and to re-establish a parodontal health to let a better domicialiar oral hygiene (Figg: 01-05).

Active retainers clinical procedure

Active retainers clinical procedure

 

The following case is a crowding case in an young female 28 years old. The intra-oral photograph systematic shows how teeth crowding was higher in the lower arc with an ectopic buccal position of tooth 43 and the shift of the lower middle line thorough the right side.

 

Initial photograph systematic

pre-treatment frontal view

Invisible Orthodontics: Class I malocclusion with impacted canine and deep bite

Invisible Orthodontics: Class I malocclusion with impacted canine and deep bite

 

The patient that came to our chairside examination showed a first class malocclusion characterized by deep bite and the upper right canine impacted(Pics 1-7).

deep bite

Invisible Orthodontics: lingual Orthodontics without brackets

Invisible Orthodontics: lingual Orthodontics without brackets

 

The request for an orthodontic treatment by patients is often motivated by the desire to improve the appearance of their smiles: more and more often they ask for an orthodontic appliance that is little annoying and completely invisible. In these cases it is possible to carry out a fixed lingual orthodontics without brackets, an innovative technique devised by Prof. Aldo Macchi in the early Nineties and first published in Italy and abroad by Prof. Macchi himself and by Dr. Nunzio Cirulli ( Macchi A, Cirulli N. “Fixed Active Retainer for Minor Anterior Tooth Movement”. Journal of Clinical Orthodontics, 2000; Macchi A, Rania S, Cirulli N . “Una proposta per la gestione di disallineamenti anteriori: il mantenitore attivo di contenzione (MAC)“).

This technique, which has undergone constant evolution over the years, has got the advantage of combining the invisibility feature of the therapy and the great comfort due to the absence of brackets touching the tongue.

The patient under examination in this work presented a Class I dental malocclusion characterized by a severe crowding of the mandibular arch (pics 1-6) and marked uneasiness in performing everyday home dental hygiene.

teeth crowdingoverjet and overbite

missing lower first molar left lateral upper arch crowding Bolton index alteration

 

The request for an invisible and little annoying treatment made by the patient drove us to carry out a lingual therapy without brackets, in this case using active retainers (pic 7).

Lingual Orthodontics

Lingual Orthodontics

 

CLINICAL CASE PERFORMED EMPLOYING FIXED LINGUAL ORTHODONTIC THERAPY WITHOUT BRACKETS

 

Lingual orthodontics rises from the need to satisfy the request, usually from adult patients, for a non visible treatment. This request can be fulfilled neither with a treatment employing porcelain buccal brackets nor with transparent trays. Both these therapies, although more aesthetically pleasant than metal buccal brackets, are not invisible: the only invisible option is lingual orthodontics.

Lingual orthodontics using brackets, despite the improvement of the brackets design over the years, can cause phonetic problems and tongue decubitus. Moreover the downsizing of the brackets in order to reduce the discomfort sometimes makes it difficult to control dental rotations and torque. This problem has only recently been overcome by Prof. Aldo Macchi’s i-TTR brackets which allow an accurate control of these parameters, as well. Prof. Macchi was also the first to perform, in the early nineties, lingual orthodontic treatments without brackets employing superelastic wires bonded on the lingual surface of the teeth.

This treatment was first carried out on patients who showed a relapse of misalignment after a previous therapy with brackets, using both the buccal and the lingual techniques. The aim was to solve the relapse avoiding a second treatment with brackets and to offer a completely invisible and comfortable solution. The subsequent step was to treat much harder cases and in patients undergoing a therapy for the first time.

The lingual therapy without brackets, subsequently performed by other authors, as well, is both invisible and extremely comfortable. Most patients who undergo lingual therapy without brackets after having undergone lingual therapy with brackets state that in the therapy without brackets they had a lot less nuisances or none at all. The phonetic alterations are hardly ever present and, when present, generally disappear in a few hours.

Lingual Orthodontics without brackets: Active Retainers

Lingual Orthodontics without brackets: Active Retainers

 

It is increasingly frequent in clinical practice to treat cases of alignment in adult patients who require a treatment which is both invisible and little annoying. This has resulted in lingual brackets becoming more and more widespread. In order to carry out an invisible and little annoying therapy, a few years ago Prof. Aldo Macchi and Dr. Nunzio Cirulli (1-2) have developed an alignment technique using Nickel Titanium wires bonded on the lingual surface of the anterior teeth. These authors have carried out lingual therapies without brackets for over 15 years. This technique has been subsequently used by other authors, as well (3-4-5).

In the present work, the authors will introduce a method of alignment using retainer wires shaped and activated, according to the biomechanical principles exposed by Burstone and Melsen (6-7-8), in order to achieve the desired dental shift.

 

Dental Procedure

 

The wires used for the dental alignment are retainers made up of 5 0.175 inches thick interweaved wires. Shaping these wires was carried out following the biomechanics laws exposed by Burstone and Melsen (6-8).

To solve the dental overcrowding vertical U loops and step bends are shaped. U loops increase the elastic properties of the wire and make it possible to increase the applied force in case of more pronounced crowdings. The step bends – that can be used without U loops in case of minimal crowdings – allow the derotation of the dental elements, as well as reducing the crowding. The wire is shaped with these bends and so to adapt to the lingual surface from canine to canine. Before the bonding procedure, the loops are opened of about 2 mm to be subsequently bonded in contraction. This way, the elastic recoil of the wire will determine the reduction of the crowding.

After cleaning the dental surfaces with toothbrush and pumice, these are etched for 30”. Afterwards the adhesive is applied and polymerized. The retainer was bonded applying fluid composite till the wire was covered for about 1 mm. Considering that after the activation the retainer will not adapt passively anymore it is necessary to bond it first to the teeth that are to be moved less and are closer to the wire. Subsequently it will be bonded on the other teeth, opening or closing the loops and pushing it, with a utility tool, on the teeth where the step bends are positioned. It is obviously necessary to keep the horizontal plane of the wire, not to bring unwanted intrusive or extrusive forces in. For this reason, especially when the wire is activated opening and closing the loops, it is important to use 2 utility tools not to let the retainer turn over.

Fixed Active Retainer (MAC): Lingual Orthodontics using active retainers

Fixed Active Retainer (MAC): Lingual Orthodontics using active retainers

 

The objective of an orthodontic treatment is to create a dental occlusion responding to aesthetic and functional canons. An even harder task is to preserve the achieved results over the years. A good diagnosis, needed to set up the treatment plan and the use, after the therapy, of a fixed or removable stabilization appliance should ensure the stability of the results. It is nonetheless possible to run into dental malpositionings in subsequent years: it is not always easy to distinguish between a relapse of the treated malocclusion and the display of a tertiary crowding (1).

In case a dental crowding appears in a patient who has already undergone an orthodontic treatment, the need to operate requires to ponder some issues. It is a fact that patients do not like putting the multi-brackets appliance again, both buccally and lingually. Another aspect to take into consideration is the further financial effort they have to undertake.

To solve these problems Prof. Aldo Macchi and Dr. Nunzio Cirulli have devised the “Fixed Active Retainer” (MAC, from the Italian “Mantenitore Attivo di Contenzione”) (2,3). This device can be used both to solve relapsing dental misalignments and to perform anterior alignment therapies in patients who have never undergone this treatment. This device, simple to apply and well tolerated by the patients, has been refined over the years by its very developers in order to be used effectively to solve more complex malocclusions. For this reason, the device dealt with in this paper is called MAC 1, in order to distinguish it from its subsequent evolutions that will be dealt with in forthcoming articles.

The MAC 1 is made up of a .012 inches thick Nickel-Titanium (Ni-Ti) wire bonded with a light-polymerizing composite resin to the teeth to be moved. The use of this aid takes advantage of the possibilities offered by Ni-Ti alloys, i.e.:

– Great elastic memory and resilience, i.e. great ability to release the energy stored up in the deformation process.

– Low modification of the stress condition during deactivation so that the applied forces are more lasting and constant in time.

These were the features of the first Ni-Ti wires, that possessed “shape memory” but did not have “superelasticity” yet. “Shape memory” (4) is the ability of the material to recall its original shape after it has been deformed plastically when it is in its stabilized martensitic form (5).

Shape memory was used by the Authors for their clinical procedure while superelasticity grants the application of constant and light forces.

Clinical Procedure

The tooth, or teeth, to be moved are etched with 37% orthophosphoric acid; subsequently the adhesive is applied. Afterwards the Ni-Ti sectional is fitted to the tooth to be moved with College pliers and is bonded with fluid composite. On the adjacent tooth, used as anchorage, the sectional is cut with a bur in order to remove excess wire. It can be necessary to reduce interproximal enamel (stripping) to regain some space in the arch.

Fixed Active Retainer (M.A.C.)

Invisible Orthodontics: Diastema closure

Invisible Orthodontics: Diastema closure

 

LINGUAL ORTHODONTICS WITHOUT BRACKETS: MECHANICS TO CLOSE SPACES

 

The aim of this work is to explain how closing the diastemas is possible in an orthodontic lingual approach without brackets.

The suggested procedures are the following:

– Retainers with vertical loops

– Sliding mechanics made with rectangular steel wires

The choice between the two types of devices depends on whether there is a need to change the shape of the arch and solve a misalignment or not. In case there is this need a retainer with loops will be used. If the shape of the arch and the position of the teeth are ideal (in buccal-lingual and occlusive-gingival sense) a sliding mechanics with rectangular steel wires will be made.

Retainers with vertical loops

 

The spaces are closed shaping vertical loops, e.g. U loops, on a 0.175 inches retainer wire.

Suppose there is the need to close a diastema between two central incisors, the mandibular ones, unlevelled in buccal-lingual sense (B-L). And suppose that the 31 is more lingually displaced than the other dental elements. It is possible to deal with this dental malposition shaping the retainer wire so that it passively adapts to the lingual surface from canine to canine. This wire will be shaped with a U loop between elements 31 and 41 and will be activated with the procedures dealt with in the previous articles (pre-activated retainers).

The loop will be closed of about 2mm (e.g. with a lingual arch plier) to activate the retainer in order to completely close the diastema. In order to activate the wire and achieve the levelling the segment to be bonded on element 41 will be bent lingually and the one to be bonded on the 31 buccally. The bending is achieved holding the first vertical segment of the loop with a plier (e.g. a bird beak plier), holding the second vertical segment of the loop with another one (e.g. a Weingart plier) and applying a torque in B-L sense. It is also possible to activate the retainer and achieve the levelling in other ways, for example making a V fold with the peak heading buccally by the segment of the wire to be bonded on the 31.

At this point the retainer is bonded according to the procedures explained in the previous articles. In the case speculated about, the wire would first be bonded on elements 33, 32, 31 – since the tooth closer to the wire is to be bonded first. Subsequently, opening the loop of about 2 mm, the wire would be bonded on elements 41, 42 and 43.

This device would be checked every 3 weeks and, in case the space is not closed, it would be detached from elements 41, 42 and 43, reactivated (closing the loop and creating an activation to move the 31 buccally, if necessary) and bonded.

After closing the space and accomplishing the alignment in B-L sense, the active retainer would be replaced with a passive one.

The following picture shows an example of spaces closed making loops on a 0.175 inches retainer wire.

Active retainers to solve anterior misalignments: an innovative Lingual Orthodontic method without brackets

Active retainers to solve anterior misalignments: an innovative Lingual Orthodontic method without brackets

The ever-increasing request for orthodontic treatment in adult patients has determined an increase in lingual orthodontics. The request for treatment is often determined by aesthetics and the need to solve misalignments of the anterior region. For this reason a new alignment method using lingually bonded elastic wires has come into being (1-2). These devices, as reported by the patients, are much more comfortable than lingual brackets.

This new lingual device was invented by Prof. Aldo Macchi and Dr. Nunzio Cirulli. In 1999 they published two articles about an innovative lingual method that used an aid they had developed called “Active Stabilization Holder” (MAC, from the Italian “Mantenitore Attivo di Contenzione”). The MAC is a fixed active retainer, made up of a .012 inches Nickel Titanium wire bonded with a light-polymerizing composite resin (1-2) to the teeth adjacent to the ones to be moved.

In 2001 Dr. Eri J. W. Liou published an article where anterior dental overcrowdings were solved using Nickel Titanium wires bonded on the lingual surface of the canines and moved to the lingual surface of the anterior and lateral incisors by means of interdental metallic retainers (3).

The dental alignment method by means of lingual orthodontics without brackets, springing from an association of the elastic properties of the wire and the principles of biomechanics, has undergone subsequent evolutions from its own creators.

These retainers are made up of 0.175 inches thick interweaved wire.

The following clinical case was carried out using this procedure.

Invisible Orthodontics

Invisible Orthodontics

 

SPACES OPEN THROUGH THE ACTIVE RETAINERS USE

 

In case of dental crowding an alignment can be made, with or without stripping, by using pre-activated retainers. Lingual orthodontics without attacks has been originally created by Dr. Aldo Macchi and Dr. Nunzio Cirulli and has also been successfully performed by other authors. This innovative technique is based on the use of retainers constituted by 5 interweaved wires of 0.0175 inches thick, shaped and activated in order to obtain the desired dental movements. Active retainers, similarly to the passive ones, are bonded on the lingual surface of the teeth. Therefore, there are invisible and they represent an ideal treatment for all patients that don’t favor the classic orthodontic therapy. Moreover, active retainers are very thin and more comfortable compared to the smaller lingual attacks. They don’t induce phonetic changes even in the first days of therapy. Thanks to all these characteristics, active retainers are actually more and more requested.

With the active retainers technique all malocclusion types may be solved: first class malocclusion with dental-basal discords, in excess or in fault, and II or III class more complex malocclusions for the latter, we also use other invisible devices such as micro screws).

Now, let’s see how it can be possible treating dental crowding with the use of active retainers. In case of a minimum dental crowding, with an inter-proximal surface overlap smaller than 0,5 mm, step folds are sufficient to develop the necessary power to align the arch. In case of a greater dental crowding it is necessary to increase wire elasticity by shaping the vertical folds in a “U” mode. Thus, charge/deflection relation is decreased, resulting in a bigger and more long-lasting activation.

In order to prepare the dental surface to the adhesion, teeth are first cleaned. Then, surfaces to be bonded are etched for 30sec and an adhesive is applied and polymerized for 20sec.

In the following figures we analyze some activations for opening spaces in case of crowding.

Invisible Orthodontics against Esthetic Orthodontics: Lingual Orthodontics without brackets through the use of pre-activated retainers

Invisible Orthodontics against Esthetic Orthodontics: Lingual Orthodontics without brackets through the use of pre-activated retainers

 

In recent years, the increase in the number of adults seeking orthodontic treatment has led to the development of ever more cosmetic therapies. Ceramic brackets, arches and cosmetic appliances are becoming more frequently employed in orthodontic treatment procedures. Nowadays, there are techniques to bring the tooth elements into proper alignment through the use of transparent masks, but this technique can be employed only in a limited number of malocclusions. All the devices listed help orthodontics to become less invisible and, therefore, more attractive but none of them are able to hide the therapy completely. The use of invisible lingual brackets is instead an entirely invisible technique, but not without causing discomfort to the patient. This irritation is due to both alterations in the phonetics as well as decubitus of the brackets on the tongue.

In my clinical work, I use lingual orthodontics without brackets through the use of super elastic threads directly bonded on the teeth. This technique, created by Professor Aldo Macchi, is considered very comfortable by patients, it does not cause any problems related to phonetics and irritation from direct contact with the tongue is rare. This therapy resulted in increased comfort for relapse patients who had previously undergone treatment with lingual brackets. In the following years other authors followed and improved such tecnique.

The patient we go on to discuss is extremely motivated to bring the dental elements into a proper alignment but done through a cosmetic orthodontic treatment.

Micro-screws in Orthodontics – clinical problems

Micro-screws in Orthodontics – clinical problems

 

The use of micro-screws in orthodontic anchorage is becoming more and more frequent in both vestibular and lingual techniques with brackets, and in more aesthetic and comfortable techniques without brackets.


Micro-screw insertion should be considered a surgical procedure as erroneous handling of the bone can easily lead to an inflammatory reaction around the screws and incorrect positioning can lead to their loosening.

Thus, in an attempt to make things clearer and to answer questions we have been asked by many of our colleagues, we can make a list of the problems that can be encountered and also share our experience in solving them.

The main problems which we can encounter when inserting a micro-screw are:

  1. Premature loosening of the micro-screw;
  2. An inflammatory reaction around the micro-screw with subsequent expulsion of the latter and the simultaneous loss of a small quantity of bone mass around the micro-screw;
  3. Micro-screw breakage;
  4. Periodontal damage when we “touch” the dental element with the micro-screw;
  5. Damage to anatomical structures close to the insertion site (vascular, neural and maxillary sinus);
  6. Decubitus ulcer on the alveolar mucosa and buccal mucosa, which often develops, above all, in the inferior dental arch.

Invisible Orthodontics: reduction of lower arch crowding by means of the pre-actived retainers

Invisible Orthodontics: reduction of lower arch crowding by means of the pre-actived retainers

On examination, the patient revealed the following clinical evaluation (fig.1-7):

  • Class I both molar right and left, Class I canine in the left side and canine to canine in the right side.
  • Provisional bridge that involves the elements 12, 11 and 22 because of loss of the element 21 due to trauma
  • Crowding in the lower arch
  • OVB of 5mm, OVJ of 2 mm
  • Periodontal health with absence of tooth pockets
  • Different type of abrasion of the inferior canines. On the right much grater abrasion than left.