- Email: [email protected]
The Invisalign Appliance Could Be an Effective Modality for Treating Overbite Malocclusions Within a Mild to Moderate Range
Accepted Manuscript DECLARATIVE TITLE: The Invisalign appliance could be an effective modality for treating overbite malocclusions within a mild to moderate range Kyungsup Shin, MS, PhD, DMD, MS PII:
S1532-3382(17)30193-8
DOI:
10.1016/j.jebdp.2017.06.010
Reference:
YMED 1215
To appear in:
The Journal of Evidence-Based Dental Practice
Please cite this article as: Shin K, DECLARATIVE TITLE: The Invisalign appliance could be an effective modality for treating overbite malocclusions within a mild to moderate range, The Journal of EvidenceBased Dental Practice (2017), doi: 10.1016/j.jebdp.2017.06.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Transmittal Journal of Evidence-Based Dental Practice
AAE
Contact information:
Elaine Steinborn 314-741-0333
M AN U
SC
Reviewer(s):
Management of overbite with the Invisalign appliance. Khosravi R, Cohanim B, Hujoel P, Daher S, Neal M, Liu W, Huang G. Am J Orthod Dentofacial Orthop 2017;151:691-99. Kyungsup Shin, MS, PhD, DMD, MS 235 Dental Science S. Department of Orthodontics College of Dentistry, University of Iowa Iowa City, IA 52242-1001 Phone: 319-335-6411 Email: [email protected]
RI PT
Article Title:
AC C
EP
TE D
[email protected]
ACCEPTED MANUSCRIPT
Article Analysis and Evaluation – Diagnosis/Treatment/Prognosis
DECLARATIVE TITLE:
ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION:
RI PT
The Invisalign appliance could be an effective modality for treating overbite malocclusions within a mild to moderate range.
SC
Management of overbite with the Invisalign appliance. Khosravi R, Cohanim B, Hujoel P, Daher S, Neal M, Liu W, Huang G. Am J Orthod Dentofacial Orthop 2017;151:69199 SOURCE OF FUNDING:
TYPE OF STUDY/DESIGN: A retrospective study
M AN U
This study was supported by the University of Washington Orthodontic Alumni Association.
REVIEWER NAME and CONTACT INFORMATION:
TE D
Kyungsup Shin, MS, PhD, DMD, MS
EP
235 Dental Science S. Department of Orthodontics College of Dentistry, University of Iowa Iowa City, IA 52242-1001 Phone: 319-335-6411 Email: [email protected]
AC C
Key Words: Invisalign, Overbite, Open bite, Deep bite Summary
Subjects:
In this retrospective study, the nature of overbite changes achieved with the Invisalign system was assessed. The study subjects consisted of 120 adult patients who underwent orthodontic treatment with the Invisalign appliances. The patients’ pretreatment and posttreatment records were collected from 3 different private orthodontic practices-2 in the greater Seattle area, Washington, and 1 in Vancouver, British Columbia.
ACCEPTED MANUSCRIPT
RI PT
Among 313 patient records initially screened, records of 193 patients were excluded mainly due to lack of final lateral cephalometric radiographs or posterior teeth not properly occluded on lateral cephalometric radiographs. Inclusion criteria were as follows: age at the beginning of treatment (18 years or older), treatment completion time (January 1, 2010 – January 1, 2014), number of aligners used for each arch (11 - 40), number of revision sets of aligners used (no more than 3), non-extraction cases, unchanged anteroposterior molar occlusal relationship, posterior-transverse occlusal relationship without significant change, and good quality of initial and final lateral cephalometric radiographs.
Key Exposure/Study Factor:
M AN U
SC
One hundred twenty patients were stratified into 3 groups based on the pretreatment overbite measured on cephalometric radiographs; 68 patients presented with a normal overbite (0 to 4 mm), 40 with a deep bite (4 mm or greater), and 12 with an open bite (negative overbite). Median ages were 32 (normal overbite), 38 (deep bite), and 30 (open bite) years. Seventy percent of the patients were female. Broken down, 46 patients (67% of the normal overbite group), 28 patients (70% of the deep bite group), and 8 patients (66% of the open bite group) were women.
TE D
The primary intervention used in this retrospective study was orthodontic treatment for dental malocclusions with the Invisalign aligners. The main records collected from the 120 cases were pretreatment and posttreatment lateral cephalometric radiographs of the individual cases. Other records collected from the selected cases included the Invisalign Treatment Overview form, the patient’s age at the start of the treatment, the patient’s gender, and questionnaires filled out by the clinicians.
EP
Main Outcome Measure:
AC C
Each subject’s lateral cephalometric radiographs were de-identified and imported into Dolphin Imaging software. To assess the changes after treatment, 10 linear and 3 angular measurements were recorded from a digitized tracing on the lateral cephalometric radiographs. Ten linear demographics consisted of overbite (OB), overjet (OJ), maxillary central incisor to palatal plane (U1-PP), mandibular central incisor to mandibular plane (L1-MP), anterior facial height (AFH), maxillary first molar to palatal plane (U6-PP), mandibular first molar to mandibular plane (L6-MP), maxillary second molar to palatal plane (U7PP), mandibular second molar to mandibular plane (L7-MP), and posterior facial height (PFH).
ACCEPTED MANUSCRIPT
Three angular demographics included maxillary central incisor-nasion-A point (U1-NA), mandibular central incisor-nasion-B point (L1-NB), and sella-nasion-mandibular plane (SN-MP).
RI PT
Nonparametric Wilcoxon signed rank test was used to examine the measurement difference before and after treatment. To investigate overbite changes in the 3 tested groups, Kruskal-Wallis analysis was used. Both of these statistical analyses were conducted at the P = .05 level of significance.
SC
Main Results:
M AN U
For patients with normal pretreatment overbite, the overbite was well-maintained with minimal change (median: -0.3 mm). Minor proclination of the maxillary (-0.7°) and mandibular (0.6°) incisors was recorded. Increases in the anterior facial height (median: 0.7 mm) and mandibular plane angle (median: 0.4°) w ere minimal within the range of measurement error.
TE D
For patients with pretreatment deep bite, overbite was reduced after the Invisalign treatment (median: -1.5-mm). Proclination of the mandibular incisors was the main mechanism of bite-opening (2.5°, P = .0201).
EP
For patients with pretreatment open bite, the Invisalign appliance deepened the overbite (median: 1.5 mm). Extrusion of the maxillary (0.9 mm) and mandibular (0.8 mm) incisors primarily contributed to open bite correction. No significant changes were observed in other linear or angular demographics.
AC C
Common treatment approaches that the 3 practitioners of this study reported were as follows: (1) normal overbite: cutting off the terminal portion of the aligners distal to the first molars and maintaining the curve of Spee, (2) deep bite: leveling the curve of Spee and using virtual bite ramps, and (3) open bite: using the attachment for incisal extrusion. Conclusions:
The authors concluded that the Invisalign appliance is relatively successful in managing overbite. It maintains the overbite in patients with normal overbite, while it can improve vertical dimensional malocclusions such as dental deep bite and dental open bite within a mild to moderate range.
ACCEPTED MANUSCRIPT
Commentary and Analysis
RI PT
Over the past 18 years, the Invisalign appliance has continued to evolve.1-3 In the early 2000s, use of the aligners was limited to the correction of very simple malocclusions such as crowding/spacing or to the treatment of minor alignment relapse.2, 3 Today, this appliance is much more widely used and used for various applications, including anteroposterior, vertical, and transverse dimensional corrections.2, 3 However, this technique, by itself, has yet to be sufficiently developed to predictably treat challenging cases that require premolar extractions, have skeletal discrepancies, or need high magnitude tooth movement.
M AN U
SC
Whether or not an aligner-type orthodontic appliance is one of a practitioner’s favorite orthodontic treatment modalities, it seems that patients’ interest in clear aligners is continually increasing.4 “Invisible” aligners can be very attractive from the patients’ perspective as they may mitigate the need for traditional brackets and wires that are “visible”. Therefore, it becomes crucial that orthodontic practitioners clearly understand the mechanics underlying aligner appliances and are able to competently treat orthodontic cases using aligners. However, many practitioners may not think it feasible to take full set of final records or do not precisely evaluate postoperative changes. As a result, they overlook the chance to thoroughly evaluate the changes that have occurred during active treatment.
AC C
EP
TE D
To date, we have only a limited number and depth of studies investigating treatment using aligners. More importantly, the majority of the reported information comes from case reports largely based on individual practitioners’ anecdotal experiences.1, 5 With regard to the efficiency (i.e., treatment time and chair time) of the Invisalign appliance, previous studies showed a significant advantage in mild to moderate cases compared to conventional fixed appliances.6, 7 However, there is insufficient evidence regarding the effectiveness and stability of aligner treatment.6, 7 It is also worth considering that ClinCheck models do not accurately reflect the final occlusion of the case and tend to overestimate the quality of the finishing evaluation.8, 9 More investigation is needed to assess the degree to which the Invisalign appliance can predictably move teeth and aid in the correction of a multidimensional malocclusion. This report provides a valuable answer for the nature of overbite changes that can be achieved with treatment using Invisalign. The authors demonstrated that the Invisalign appliance is a relatively successful treatment option for managing mild to moderate overbite problems. Valid records (pretreatment and posttreatment cephalometric radiographs) and reliable information (linear and angular measurements from the cephalometric radiographs tracing) were used in this study. The authors reported the magnitudes of vertical dimension (median 1.5 mm for both deep bite and open bite) that were effectively corrected using the Invisalign appliance. The primary causes of the
ACCEPTED MANUSCRIPT
RI PT
corrections were also explained; mandibular incisal proclination and molar extrusion for opening the bite, and maxillary/mandibular incisal extrusion for deepening the bite. These findings were congruent with previous reports,2, 3, 10, 11 and practitioners can use this information when clinically assessing potential patients and their specific malocclusions for orthodontic treatment with the clear aligners. Additionally, this report is a great initiative model for the National Dental Practice-based Research Network (PBRN), where dental practitioners can participate in multi-centered clinical research with their clinical expertise and records from their clinics (https://www.nationaldentalpbrn.org).
TE D
M AN U
SC
This report, however, has some limitations. Readers need to be mindful of the fact that only mild to moderate cases were assessed in this study and no information was provided to ascertain how well the Invisalign appliance would function in the correction of cases presenting with severe deep bite or open bite. It is also worth noting that the inclusion criteria of this study limited the selected cases to those that were relatively simple to treat and did not require anteroposterior or transverse correction, but only vertical changes. Therefore, the outcomes may be different in more complex cases, such as those needing multidimensional corrections (anteroposterior, transverse as well as vertical) or those involving space closure after tooth extraction. This study also did not include an assessment on treatment results using conventional fixed appliances as has been done in previous studies.5, 6 Thus, any information with regard to the effectiveness of vertical correction by the aligner appliance should not be interpreted in comparison with conventional fixed appliances.
AC C
EP
Further studies are needed to evaluate the evolution of the Invisalign appliance and its expanded applications. Aligners will likely keep evolving with new designs/sizes of attachments, modification of auxiliaries, and potentially new tray materials. Temporary Anchorage Devices (TAD)-supported aligner treatment is an example that can expand the role of aligners to include more difficult cases and tooth movements. For example, TADs can help to intrude posterior teeth to manage severe open bite cases or, conversely, intrude anterior teeth to correct severe deep bite maloccusions. Other areas of study may include cases treated with aligners that involve tooth extraction, orthopedics, orthognathic surgery, or accelerated tooth movement. Eventually, practitioners who keep up with evidence-based studies on the orthodontic aligners will have more reliable clinical guidelines so that they can competently select this treatment modality to provide patient-specific orthodontic care.
Strength of Recommendation Taxonomy (SORT) Grading LEVEL OF EVIDENCE:
ACCEPTED MANUSCRIPT
Level 2
Limited-quality, patient-oriented evidence
References
5.
6.
7.
8.
9.
10.
SC
M AN U
4.
TE D
3.
EP
2.
Wheeler TT. Orthodontic clear aligner treatment. Semin Orthod 2017;23(1):83-9. Schupp W, Haubrich J, Neumann I. Treatment of anterior open bite with the Invisalign system. J Clin Orthod 2010;44:501-7. Giancotti A, Garino F, Mampieri G. Use of clear aligners in open bite cases: an unexpected treatment option. J Orthod 2017:1-12. Walton DK, Fields HW, Johnston WM, Rosenstiel SF, Firestone AR, Christensen JC. Orthodontic appliance preferences of children and adolescents. Am J Orthod Dentofac Orthop 2010;138(6):691-8. Djeu G, Shelton C, Maganzini A. Outcome assessment of Invisalign and traditional orthodontic treatment compared with the American Board of Orthodontics objective grading system. Am J Orthod Dentofac Orthop 2005;128:292-8. Gu J, Tang JS, Skulski B, et al. Evaluation of Invisalign treatment effectiveness and efficiency compared with conventional fixed appliances using the Peer Assessment Rating index. Am J Orthod Dentofac Orthop 2017;151:259-66. Zheng M, Liu R, Ni Z, Yu Z. Efficiency, effectiveness and treatment stability of clear aligners: A systematic review and meta-analysis. Orthod Craniofac Res 2017:1-7, DOI:10.1111/ocr.12177 Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agran B. How well does Invisalign work? A prospective clinical study evaluating the efficacy of tooth movement with Invisalign. Am J Orthod Dentofac Orthop 2009;135:27-35. Buschang PH, Ross M, Shaw SG, Crosby D, Campbell PM. Predicted and actual end-of-treatment occlusion produced with aligner therapy. Angle Orthod 2014;85:723-7. Giancotti A, Mampieri G, Greco M. Correction of deep bite in adults using the Invisalign system. J Clin Orthod 2008;42:719-26.
AC C
1.
RI PT
STRENGTH OF RECOMMENDATION GRADE: N/A
ACCEPTED MANUSCRIPT
EP
TE D
M AN U
SC
RI PT
Guarneri MP, Oliverio T, Silvestre I, Lombardo L, Siciliani G. Open bite treatment using clear aligners. Angle Orthod 2013;83:913-9.
AC C
11.
S1532-3382(17)30193-8
DOI:
10.1016/j.jebdp.2017.06.010
Reference:
YMED 1215
To appear in:
The Journal of Evidence-Based Dental Practice
Please cite this article as: Shin K, DECLARATIVE TITLE: The Invisalign appliance could be an effective modality for treating overbite malocclusions within a mild to moderate range, The Journal of EvidenceBased Dental Practice (2017), doi: 10.1016/j.jebdp.2017.06.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Transmittal Journal of Evidence-Based Dental Practice
AAE
Contact information:
Elaine Steinborn 314-741-0333
M AN U
SC
Reviewer(s):
Management of overbite with the Invisalign appliance. Khosravi R, Cohanim B, Hujoel P, Daher S, Neal M, Liu W, Huang G. Am J Orthod Dentofacial Orthop 2017;151:691-99. Kyungsup Shin, MS, PhD, DMD, MS 235 Dental Science S. Department of Orthodontics College of Dentistry, University of Iowa Iowa City, IA 52242-1001 Phone: 319-335-6411 Email: [email protected]
RI PT
Article Title:
AC C
EP
TE D
[email protected]
ACCEPTED MANUSCRIPT
Article Analysis and Evaluation – Diagnosis/Treatment/Prognosis
DECLARATIVE TITLE:
ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION:
RI PT
The Invisalign appliance could be an effective modality for treating overbite malocclusions within a mild to moderate range.
SC
Management of overbite with the Invisalign appliance. Khosravi R, Cohanim B, Hujoel P, Daher S, Neal M, Liu W, Huang G. Am J Orthod Dentofacial Orthop 2017;151:69199 SOURCE OF FUNDING:
TYPE OF STUDY/DESIGN: A retrospective study
M AN U
This study was supported by the University of Washington Orthodontic Alumni Association.
REVIEWER NAME and CONTACT INFORMATION:
TE D
Kyungsup Shin, MS, PhD, DMD, MS
EP
235 Dental Science S. Department of Orthodontics College of Dentistry, University of Iowa Iowa City, IA 52242-1001 Phone: 319-335-6411 Email: [email protected]
AC C
Key Words: Invisalign, Overbite, Open bite, Deep bite Summary
Subjects:
In this retrospective study, the nature of overbite changes achieved with the Invisalign system was assessed. The study subjects consisted of 120 adult patients who underwent orthodontic treatment with the Invisalign appliances. The patients’ pretreatment and posttreatment records were collected from 3 different private orthodontic practices-2 in the greater Seattle area, Washington, and 1 in Vancouver, British Columbia.
ACCEPTED MANUSCRIPT
RI PT
Among 313 patient records initially screened, records of 193 patients were excluded mainly due to lack of final lateral cephalometric radiographs or posterior teeth not properly occluded on lateral cephalometric radiographs. Inclusion criteria were as follows: age at the beginning of treatment (18 years or older), treatment completion time (January 1, 2010 – January 1, 2014), number of aligners used for each arch (11 - 40), number of revision sets of aligners used (no more than 3), non-extraction cases, unchanged anteroposterior molar occlusal relationship, posterior-transverse occlusal relationship without significant change, and good quality of initial and final lateral cephalometric radiographs.
Key Exposure/Study Factor:
M AN U
SC
One hundred twenty patients were stratified into 3 groups based on the pretreatment overbite measured on cephalometric radiographs; 68 patients presented with a normal overbite (0 to 4 mm), 40 with a deep bite (4 mm or greater), and 12 with an open bite (negative overbite). Median ages were 32 (normal overbite), 38 (deep bite), and 30 (open bite) years. Seventy percent of the patients were female. Broken down, 46 patients (67% of the normal overbite group), 28 patients (70% of the deep bite group), and 8 patients (66% of the open bite group) were women.
TE D
The primary intervention used in this retrospective study was orthodontic treatment for dental malocclusions with the Invisalign aligners. The main records collected from the 120 cases were pretreatment and posttreatment lateral cephalometric radiographs of the individual cases. Other records collected from the selected cases included the Invisalign Treatment Overview form, the patient’s age at the start of the treatment, the patient’s gender, and questionnaires filled out by the clinicians.
EP
Main Outcome Measure:
AC C
Each subject’s lateral cephalometric radiographs were de-identified and imported into Dolphin Imaging software. To assess the changes after treatment, 10 linear and 3 angular measurements were recorded from a digitized tracing on the lateral cephalometric radiographs. Ten linear demographics consisted of overbite (OB), overjet (OJ), maxillary central incisor to palatal plane (U1-PP), mandibular central incisor to mandibular plane (L1-MP), anterior facial height (AFH), maxillary first molar to palatal plane (U6-PP), mandibular first molar to mandibular plane (L6-MP), maxillary second molar to palatal plane (U7PP), mandibular second molar to mandibular plane (L7-MP), and posterior facial height (PFH).
ACCEPTED MANUSCRIPT
Three angular demographics included maxillary central incisor-nasion-A point (U1-NA), mandibular central incisor-nasion-B point (L1-NB), and sella-nasion-mandibular plane (SN-MP).
RI PT
Nonparametric Wilcoxon signed rank test was used to examine the measurement difference before and after treatment. To investigate overbite changes in the 3 tested groups, Kruskal-Wallis analysis was used. Both of these statistical analyses were conducted at the P = .05 level of significance.
SC
Main Results:
M AN U
For patients with normal pretreatment overbite, the overbite was well-maintained with minimal change (median: -0.3 mm). Minor proclination of the maxillary (-0.7°) and mandibular (0.6°) incisors was recorded. Increases in the anterior facial height (median: 0.7 mm) and mandibular plane angle (median: 0.4°) w ere minimal within the range of measurement error.
TE D
For patients with pretreatment deep bite, overbite was reduced after the Invisalign treatment (median: -1.5-mm). Proclination of the mandibular incisors was the main mechanism of bite-opening (2.5°, P = .0201).
EP
For patients with pretreatment open bite, the Invisalign appliance deepened the overbite (median: 1.5 mm). Extrusion of the maxillary (0.9 mm) and mandibular (0.8 mm) incisors primarily contributed to open bite correction. No significant changes were observed in other linear or angular demographics.
AC C
Common treatment approaches that the 3 practitioners of this study reported were as follows: (1) normal overbite: cutting off the terminal portion of the aligners distal to the first molars and maintaining the curve of Spee, (2) deep bite: leveling the curve of Spee and using virtual bite ramps, and (3) open bite: using the attachment for incisal extrusion. Conclusions:
The authors concluded that the Invisalign appliance is relatively successful in managing overbite. It maintains the overbite in patients with normal overbite, while it can improve vertical dimensional malocclusions such as dental deep bite and dental open bite within a mild to moderate range.
ACCEPTED MANUSCRIPT
Commentary and Analysis
RI PT
Over the past 18 years, the Invisalign appliance has continued to evolve.1-3 In the early 2000s, use of the aligners was limited to the correction of very simple malocclusions such as crowding/spacing or to the treatment of minor alignment relapse.2, 3 Today, this appliance is much more widely used and used for various applications, including anteroposterior, vertical, and transverse dimensional corrections.2, 3 However, this technique, by itself, has yet to be sufficiently developed to predictably treat challenging cases that require premolar extractions, have skeletal discrepancies, or need high magnitude tooth movement.
M AN U
SC
Whether or not an aligner-type orthodontic appliance is one of a practitioner’s favorite orthodontic treatment modalities, it seems that patients’ interest in clear aligners is continually increasing.4 “Invisible” aligners can be very attractive from the patients’ perspective as they may mitigate the need for traditional brackets and wires that are “visible”. Therefore, it becomes crucial that orthodontic practitioners clearly understand the mechanics underlying aligner appliances and are able to competently treat orthodontic cases using aligners. However, many practitioners may not think it feasible to take full set of final records or do not precisely evaluate postoperative changes. As a result, they overlook the chance to thoroughly evaluate the changes that have occurred during active treatment.
AC C
EP
TE D
To date, we have only a limited number and depth of studies investigating treatment using aligners. More importantly, the majority of the reported information comes from case reports largely based on individual practitioners’ anecdotal experiences.1, 5 With regard to the efficiency (i.e., treatment time and chair time) of the Invisalign appliance, previous studies showed a significant advantage in mild to moderate cases compared to conventional fixed appliances.6, 7 However, there is insufficient evidence regarding the effectiveness and stability of aligner treatment.6, 7 It is also worth considering that ClinCheck models do not accurately reflect the final occlusion of the case and tend to overestimate the quality of the finishing evaluation.8, 9 More investigation is needed to assess the degree to which the Invisalign appliance can predictably move teeth and aid in the correction of a multidimensional malocclusion. This report provides a valuable answer for the nature of overbite changes that can be achieved with treatment using Invisalign. The authors demonstrated that the Invisalign appliance is a relatively successful treatment option for managing mild to moderate overbite problems. Valid records (pretreatment and posttreatment cephalometric radiographs) and reliable information (linear and angular measurements from the cephalometric radiographs tracing) were used in this study. The authors reported the magnitudes of vertical dimension (median 1.5 mm for both deep bite and open bite) that were effectively corrected using the Invisalign appliance. The primary causes of the
ACCEPTED MANUSCRIPT
RI PT
corrections were also explained; mandibular incisal proclination and molar extrusion for opening the bite, and maxillary/mandibular incisal extrusion for deepening the bite. These findings were congruent with previous reports,2, 3, 10, 11 and practitioners can use this information when clinically assessing potential patients and their specific malocclusions for orthodontic treatment with the clear aligners. Additionally, this report is a great initiative model for the National Dental Practice-based Research Network (PBRN), where dental practitioners can participate in multi-centered clinical research with their clinical expertise and records from their clinics (https://www.nationaldentalpbrn.org).
TE D
M AN U
SC
This report, however, has some limitations. Readers need to be mindful of the fact that only mild to moderate cases were assessed in this study and no information was provided to ascertain how well the Invisalign appliance would function in the correction of cases presenting with severe deep bite or open bite. It is also worth noting that the inclusion criteria of this study limited the selected cases to those that were relatively simple to treat and did not require anteroposterior or transverse correction, but only vertical changes. Therefore, the outcomes may be different in more complex cases, such as those needing multidimensional corrections (anteroposterior, transverse as well as vertical) or those involving space closure after tooth extraction. This study also did not include an assessment on treatment results using conventional fixed appliances as has been done in previous studies.5, 6 Thus, any information with regard to the effectiveness of vertical correction by the aligner appliance should not be interpreted in comparison with conventional fixed appliances.
AC C
EP
Further studies are needed to evaluate the evolution of the Invisalign appliance and its expanded applications. Aligners will likely keep evolving with new designs/sizes of attachments, modification of auxiliaries, and potentially new tray materials. Temporary Anchorage Devices (TAD)-supported aligner treatment is an example that can expand the role of aligners to include more difficult cases and tooth movements. For example, TADs can help to intrude posterior teeth to manage severe open bite cases or, conversely, intrude anterior teeth to correct severe deep bite maloccusions. Other areas of study may include cases treated with aligners that involve tooth extraction, orthopedics, orthognathic surgery, or accelerated tooth movement. Eventually, practitioners who keep up with evidence-based studies on the orthodontic aligners will have more reliable clinical guidelines so that they can competently select this treatment modality to provide patient-specific orthodontic care.
Strength of Recommendation Taxonomy (SORT) Grading LEVEL OF EVIDENCE:
ACCEPTED MANUSCRIPT
Level 2
Limited-quality, patient-oriented evidence
References
5.
6.
7.
8.
9.
10.
SC
M AN U
4.
TE D
3.
EP
2.
Wheeler TT. Orthodontic clear aligner treatment. Semin Orthod 2017;23(1):83-9. Schupp W, Haubrich J, Neumann I. Treatment of anterior open bite with the Invisalign system. J Clin Orthod 2010;44:501-7. Giancotti A, Garino F, Mampieri G. Use of clear aligners in open bite cases: an unexpected treatment option. J Orthod 2017:1-12. Walton DK, Fields HW, Johnston WM, Rosenstiel SF, Firestone AR, Christensen JC. Orthodontic appliance preferences of children and adolescents. Am J Orthod Dentofac Orthop 2010;138(6):691-8. Djeu G, Shelton C, Maganzini A. Outcome assessment of Invisalign and traditional orthodontic treatment compared with the American Board of Orthodontics objective grading system. Am J Orthod Dentofac Orthop 2005;128:292-8. Gu J, Tang JS, Skulski B, et al. Evaluation of Invisalign treatment effectiveness and efficiency compared with conventional fixed appliances using the Peer Assessment Rating index. Am J Orthod Dentofac Orthop 2017;151:259-66. Zheng M, Liu R, Ni Z, Yu Z. Efficiency, effectiveness and treatment stability of clear aligners: A systematic review and meta-analysis. Orthod Craniofac Res 2017:1-7, DOI:10.1111/ocr.12177 Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agran B. How well does Invisalign work? A prospective clinical study evaluating the efficacy of tooth movement with Invisalign. Am J Orthod Dentofac Orthop 2009;135:27-35. Buschang PH, Ross M, Shaw SG, Crosby D, Campbell PM. Predicted and actual end-of-treatment occlusion produced with aligner therapy. Angle Orthod 2014;85:723-7. Giancotti A, Mampieri G, Greco M. Correction of deep bite in adults using the Invisalign system. J Clin Orthod 2008;42:719-26.
AC C
1.
RI PT
STRENGTH OF RECOMMENDATION GRADE: N/A
ACCEPTED MANUSCRIPT
EP
TE D
M AN U
SC
RI PT
Guarneri MP, Oliverio T, Silvestre I, Lombardo L, Siciliani G. Open bite treatment using clear aligners. Angle Orthod 2013;83:913-9.
AC C
11.