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The Invisalign Appliance Could Be an Effective Modality for Treating Overbite Malocclusions Within a Mild to Moderate Range
The Journal of EVIDENCE-BASED DENTAL PRACTICE
ARTICLE ANALYSIS & EVALUATION // DIAGNOSIS/TREATMENT/PROGNOSIS
THE INVISALIGN APPLIANCE COULD BE AN EFFECTIVE MODALITY FOR TREATING OVERBITE MALOCCLUSIONS WITHIN A MILD TO MODERATE RANGE REVIEWER
KYUNGSUP SHIN Do Invisalign aligners provide effective treatment for overbite and vertical dimensional malocclusions? What overbite changes can be achieved using Invisalign aligners?
A
SORT SCORE B C
N/A
SORT, Strength of Recommendation Taxonomy
LEVEL OF EVIDENCE 1 2 3 See page 9A for complete details regarding SORT and LEVEL OF EVIDENCE grading system
SOURCE OF FUNDING This study was supported by the University of Washington Orthodontic Alumni Association
TYPE OF STUDY/DESIGN A retrospective study
KEYWORDS Invisalign, Overbite, Open bite, Deep bite
J Evid Base Dent Pract 2017: [278-280] 1532-3382/$36.00 ª 2017 Elsevier Inc. All rights reserved. doi: http://dx.doi.org/10.1016/ j.jebdp.2017.06.010
278
Volume 17, Number 3
ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION 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;151:691-9.
SUMMARY Subjects In this retrospective study, the nature of overbite (OB) 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 post-treatment records were collected from 3 different private orthodontic practices—2 in the greater Seattle area, Washington, and 1 in Vancouver, British Columbia. Among 313 patient records initially screened, records of 193 patients were excluded mainly due to the 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), nonextraction cases, unchanged anteroposterior molar occlusal relationship, posterior-transverse occlusal relationship without significant change, and good quality of initial and final lateral cephalometric radiographs. One hundred twenty patients were stratified into 3 groups based on the pretreatment OB measured on cephalometric radiographs; 68 patients presented with a normal OB (0-4 mm), 40 with a deep bite (4 mm or greater), and 12 with an open bite (negative OB). Median ages were 32 (normal OB), 38 (deep bite), and 30 (open bite) years. Seventy percent of the patients were female. Of the 120 patients, 46 patients (67% of the normal OB group), 28 patients (70% of the deep bite group), and 8 patients (66% of the open bite group) were women.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Key Exposure/Study Factor 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 post-treatment 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.
Main Outcome Measure Each subject’s lateral cephalometric radiographs were deidentified 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 OB, overjet, maxillary central incisor to palatal plane (U1-PP), mandibular central incisor to mandibular plane (L1-MP), anterior facial height, maxillary first molar to palatal plane (U6-PP), mandibular first molar to mandibular plane (L6-MP), maxillary second molar to palatal plane (U7-PP), mandibular second molar to mandibular plane (L7-MP), and posterior facial height. Three angular demographics included maxillary central incisor-nasion-A point (U1-NA), mandibular central incisornasion-B point (L1-NB), and sella-nasion-mandibular plane (SN-MP). Nonparametric Wilcoxon signed rank test was used to examine the measurement difference before and after treatment. To investigate OB changes in the 3 tested groups, Kruskal–Wallis analysis was used. Both of these statistical analyses were conducted at the P 5 .05 level of significance.
Main Results For patients with normal pretreatment OB, the OB was well maintained with minimal change (median: 20.3 mm). Minor proclination of the maxillary (20.7 ) and mandibular (0.6 ) incisors was recorded. Increases in the anterior facial height (median: 0.7 mm) and mandibular plane angle (median: 0.4 ) were minimal within the range of measurement error. For patients with pretreatment deep bite, OB was reduced after the Invisalign treatment (median: 21.5 mm). Proclination of the mandibular incisors was the main mechanism of bite opening (2.5 , P 5 .0201). For patients with pretreatment open bite, the Invisalign appliance deepened the OB (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.
Common treatment approaches that the 3 practitioners of this study reported were as follows: (1) normal OB: 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 OB. It maintains the OB in patients with normal OB, whereas it can improve vertical dimensional malocclusions such as dental deep bite and dental open bite within a mild to moderate range.
COMMENTARY AND ANALYSIS Over the past 18 years, the Invisalign appliance has continued to evolve.1-3 In the early 2000s, the 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 highmagnitude tooth movement. 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. 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 (ie, treatment time and chair time) of the Invisalign appliance, previous studies showed a significant advantage in mild to moderate cases compared with 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
September 2017
279
The Journal of EVIDENCE-BASED DENTAL PRACTICE
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 OB 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 OB problems. Valid records (pretreatment and post-treatment 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 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. In addition, this report is a great initiative model for the National Dental Practice-based Research Network, where dental practitioners can participate in multicentered clinical research with their clinical expertise and records from their clinics (https://www.nationaldentalpbrn.org). 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, and 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. 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–supported aligner treatment is an example that can expand the role of aligners to include more difficult cases and tooth movements. For example,
280
Volume 17, Number 3
temporary anchorage devices can help to intrude posterior teeth to manage severe open bite cases or, conversely, intrude anterior teeth to correct severe deep-bite malocclusions. 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.
REFERENCES 1. Wheeler TT. Orthodontic clear aligner treatment. Semin Orthod 2017;23(1):83-9. 2. Schupp W, Haubrich J, Neumann I. Treatment of anterior open bite with the Invisalign system. J Clin Orthod 2010;44:501-7. 3. Giancotti A, Garino F, Mampieri G. Use of clear aligners in open bite cases: an unexpected treatment option. J Orthod 2017;44:114-25. 4. Walton DK, Fields HW, Johnston WM, Rosenstiel SF, Firestone AR, Christensen JC. Orthodontic appliance preferences of children and adolescents. Am J Orthod Dentofacial Orthop 2010;138(6):691-8. 5. 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 Dentofacial Orthop 2005;128:292-8. 6. 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 Dentofacial Orthop 2017;151:259-66. 7. 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. http://dx.doi.org/10.1111/ ocr.12177. 8. 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 Dentofacial Orthop 2009;135:27-35. 9. 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. 10. Giancotti A, Mampieri G, Greco M. Correction of deep bite in adults using the Invisalign system. J Clin Orthod 2008;42:719-26. 11. Guarneri MP, Oliverio T, Silvestre I, Lombardo L, Siciliani G. Open bite treatment using clear aligners. Angle Orthod 2013;83:913-9.
REVIEWER Kyungsup Shin, MS, PhD, DMD, MS Department of Orthodontics, College of Dentistry, University of Iowa, Iowa City, IA, USA, [email protected]
ARTICLE ANALYSIS & EVALUATION // DIAGNOSIS/TREATMENT/PROGNOSIS
THE INVISALIGN APPLIANCE COULD BE AN EFFECTIVE MODALITY FOR TREATING OVERBITE MALOCCLUSIONS WITHIN A MILD TO MODERATE RANGE REVIEWER
KYUNGSUP SHIN Do Invisalign aligners provide effective treatment for overbite and vertical dimensional malocclusions? What overbite changes can be achieved using Invisalign aligners?
A
SORT SCORE B C
N/A
SORT, Strength of Recommendation Taxonomy
LEVEL OF EVIDENCE 1 2 3 See page 9A for complete details regarding SORT and LEVEL OF EVIDENCE grading system
SOURCE OF FUNDING This study was supported by the University of Washington Orthodontic Alumni Association
TYPE OF STUDY/DESIGN A retrospective study
KEYWORDS Invisalign, Overbite, Open bite, Deep bite
J Evid Base Dent Pract 2017: [278-280] 1532-3382/$36.00 ª 2017 Elsevier Inc. All rights reserved. doi: http://dx.doi.org/10.1016/ j.jebdp.2017.06.010
278
Volume 17, Number 3
ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION 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;151:691-9.
SUMMARY Subjects In this retrospective study, the nature of overbite (OB) 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 post-treatment records were collected from 3 different private orthodontic practices—2 in the greater Seattle area, Washington, and 1 in Vancouver, British Columbia. Among 313 patient records initially screened, records of 193 patients were excluded mainly due to the 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), nonextraction cases, unchanged anteroposterior molar occlusal relationship, posterior-transverse occlusal relationship without significant change, and good quality of initial and final lateral cephalometric radiographs. One hundred twenty patients were stratified into 3 groups based on the pretreatment OB measured on cephalometric radiographs; 68 patients presented with a normal OB (0-4 mm), 40 with a deep bite (4 mm or greater), and 12 with an open bite (negative OB). Median ages were 32 (normal OB), 38 (deep bite), and 30 (open bite) years. Seventy percent of the patients were female. Of the 120 patients, 46 patients (67% of the normal OB group), 28 patients (70% of the deep bite group), and 8 patients (66% of the open bite group) were women.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Key Exposure/Study Factor 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 post-treatment 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.
Main Outcome Measure Each subject’s lateral cephalometric radiographs were deidentified 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 OB, overjet, maxillary central incisor to palatal plane (U1-PP), mandibular central incisor to mandibular plane (L1-MP), anterior facial height, maxillary first molar to palatal plane (U6-PP), mandibular first molar to mandibular plane (L6-MP), maxillary second molar to palatal plane (U7-PP), mandibular second molar to mandibular plane (L7-MP), and posterior facial height. Three angular demographics included maxillary central incisor-nasion-A point (U1-NA), mandibular central incisornasion-B point (L1-NB), and sella-nasion-mandibular plane (SN-MP). Nonparametric Wilcoxon signed rank test was used to examine the measurement difference before and after treatment. To investigate OB changes in the 3 tested groups, Kruskal–Wallis analysis was used. Both of these statistical analyses were conducted at the P 5 .05 level of significance.
Main Results For patients with normal pretreatment OB, the OB was well maintained with minimal change (median: 20.3 mm). Minor proclination of the maxillary (20.7 ) and mandibular (0.6 ) incisors was recorded. Increases in the anterior facial height (median: 0.7 mm) and mandibular plane angle (median: 0.4 ) were minimal within the range of measurement error. For patients with pretreatment deep bite, OB was reduced after the Invisalign treatment (median: 21.5 mm). Proclination of the mandibular incisors was the main mechanism of bite opening (2.5 , P 5 .0201). For patients with pretreatment open bite, the Invisalign appliance deepened the OB (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.
Common treatment approaches that the 3 practitioners of this study reported were as follows: (1) normal OB: 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 OB. It maintains the OB in patients with normal OB, whereas it can improve vertical dimensional malocclusions such as dental deep bite and dental open bite within a mild to moderate range.
COMMENTARY AND ANALYSIS Over the past 18 years, the Invisalign appliance has continued to evolve.1-3 In the early 2000s, the 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 highmagnitude tooth movement. 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. 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 (ie, treatment time and chair time) of the Invisalign appliance, previous studies showed a significant advantage in mild to moderate cases compared with 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
September 2017
279
The Journal of EVIDENCE-BASED DENTAL PRACTICE
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 OB 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 OB problems. Valid records (pretreatment and post-treatment 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 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. In addition, this report is a great initiative model for the National Dental Practice-based Research Network, where dental practitioners can participate in multicentered clinical research with their clinical expertise and records from their clinics (https://www.nationaldentalpbrn.org). 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, and 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. 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–supported aligner treatment is an example that can expand the role of aligners to include more difficult cases and tooth movements. For example,
280
Volume 17, Number 3
temporary anchorage devices can help to intrude posterior teeth to manage severe open bite cases or, conversely, intrude anterior teeth to correct severe deep-bite malocclusions. 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.
REFERENCES 1. Wheeler TT. Orthodontic clear aligner treatment. Semin Orthod 2017;23(1):83-9. 2. Schupp W, Haubrich J, Neumann I. Treatment of anterior open bite with the Invisalign system. J Clin Orthod 2010;44:501-7. 3. Giancotti A, Garino F, Mampieri G. Use of clear aligners in open bite cases: an unexpected treatment option. J Orthod 2017;44:114-25. 4. Walton DK, Fields HW, Johnston WM, Rosenstiel SF, Firestone AR, Christensen JC. Orthodontic appliance preferences of children and adolescents. Am J Orthod Dentofacial Orthop 2010;138(6):691-8. 5. 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 Dentofacial Orthop 2005;128:292-8. 6. 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 Dentofacial Orthop 2017;151:259-66. 7. 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. http://dx.doi.org/10.1111/ ocr.12177. 8. 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 Dentofacial Orthop 2009;135:27-35. 9. 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. 10. Giancotti A, Mampieri G, Greco M. Correction of deep bite in adults using the Invisalign system. J Clin Orthod 2008;42:719-26. 11. Guarneri MP, Oliverio T, Silvestre I, Lombardo L, Siciliani G. Open bite treatment using clear aligners. Angle Orthod 2013;83:913-9.
REVIEWER Kyungsup Shin, MS, PhD, DMD, MS Department of Orthodontics, College of Dentistry, University of Iowa, Iowa City, IA, USA, [email protected]