Invisalign versus implant therapy

Case presentation: Invisalign versus implant therapy

Every day we are faced with challenging cases. Should we extract, file down or build up?

But with experience one begins to understand which treatments work, which are too outlandish and which should never have been started.

However when a tooth is destined for removal then the resultant space presents a dilemma.

Should we restore the space or should we prepare adjacent teeth for a bridge and thereby reduce the life expectancy of these teeth as well.

Restoring a space has evolved from dentures to the use of dental implants, mini or maxi. Even if a mini implant can be used, does the patient want implants and will there be adequate space for a reasonably life like crown?

It seems logical that if the space is too small to restore then we should try to close the space instead of opening it up for an implant. This option is gentler, quicker and less expensive.

A delightful lady was referred to me for an opinion on how to restore a failing UR2 post crown.

She came with her husband and I have to say that we got on right from the start.

The lady was 60 years of age and in good health. Her dentition was relatively unrestored and she had good oral hygiene.

Her brother in law was a dentist and had read one of my articles on Invisalign and hence referred the patient to me for a solution.

She presented as follows:

  • Class 2 skeletal base
  • Class 2 div 2 dental crowding
  • RHS canine was full class 2 and rotated
  • LHS canine was half class 2
  • Overbite was slightly deep
  • Centrelines incoincident
  • Arch collapse laterally especially RHS with slight open bite
  • Upper central incisors were retroclined and the laterals were crowded

Initial presentation:

forma-blog

UR2 had been prepared to bring it into the arch 35 years ago with a metal porcelain post crown.

It was very long and had a tapered crown. The length signified that the tooth must have sat very high labially but would have been short at the incisal edge.

It had a vertical root fracture and was beyond saving. The problem was that the root was still outside the dental arch and the interproximal space was about 3mm.

There was no room for a dental implant so the options discussed were:

  • Orthodontic distalisation of RHS segment to create space for an implant
  • Cantilever bridge from UR3 with a similar pontic
  • Fixed UR13 bridge
  • Denture
  • Close space orthodontically

As the patient had class 2 div 2 dental crowding I advised the patient that we could use Invisalgn to:

  • Upright the centrals
  • reduce the overbite
  • correct lateral arch collapse
  • correct lower crowding
  • close UR2 space
  • preserve her natural teeth

The problems that I had were as follows:

  • Would the gap close?
  • Would the gum line be uneven?
  • Should I have waited for soft tissue maturation?
  • Will uprighting her arch create more space when we are trying to close a space?
  • Would the patient accept the attachments?
  • UR3 class 1 was not going to be the goal here
  • Correcting centre line would have created more space RHS to then have to close

Patient agreed on Invisalign treatment as she wanted to preserve her natural teeth. She was happy not to correct the centre line because her UR2 space closure was her priority.

Her brother in law removed the UR2 and she came in for impressions.

Invisalign scans were produced and the images are shown as below:

form-blog-2

There were 28 upper and 11 lower aligners. The treatment included :

  • Arch expansion by derotating 654/456
  • There was some IPR required LHS to improve the canine position
  • Uprighting central incisors
  • Intruding upper incisors to reduce overbite and bringing the UR1 closer to UR3
  • Intruding lower incisors to flatten occlusal plane
  • Derotating UR3 mesially towards UR2 space

The aligners were custom made for each individual stage and there was no pontic allowed UR2 due to lack of space.

The patient changed each aligner every 2 weeks and came on Saturdays every 8 weeks for a review.

Her oral hygiene was impeccable and she had only 1 problem and that was a slightly dry mouth with the aligners.

The space was less noticeable with the aligners in due to the natural reflection of the material.

The patient had no problems in removing the aligners and she started to notice how her smile widened with throughout the treatment.

Once the lower treatment aligners were finished we carried out some minor refinement.

After approximately 15 months the treatment was finished.

forma-blog-3

You will notice that the UR2 space closed completely and moving the canine mesially created an incisive papilla. Lower gum line is even as well. The occlusal photo shows a nicely rounded arch.

forma-blog-4

“The teeth are still looking good, I am really pleased that I had them done, money worth spending ( one less holiday!)”

Conclusion

If a patient has had healthy teeth for over 55 years then why would she want them filed down for a bridge? It is never too late to do Invisalign.

Leave a Reply