The rising demand for clear aligner therapy: How to be efficient, predictable, and profitable

A 45-year-old male presented to my office for initial evaluation and consultation. We collected a full set of dental records and performed a comprehensive clinical examination to develop a diagnosis and treatment plan.The smile photograph shows a deficient smile line with a canine-to-canine view and empty buccal corridors (figure 1). The patient had a dental diagnosis of class II crowded malocclusion, with an underlying cause of maxillary

underdevelopment (figure 2). He had a history of teenage bracket and wire extraction orthodontics, at which time teeth nos. 5 and 12 were extracted as part of treatment. The patient also reported mild and infrequent TMD symptoms. He had an improper arch form, described as an omega-shaped arch form. By taking a transverse measurement between the upper first molars, it was determined that the patient had an improper arch width.

Primary issues

The patient had three primary issues:

• He measured 28 mm, which is very narrow considering that uncrowded adults measure 35 mm–39 mm.
• His narrow maxilla had a corresponding vaulted palate, which is clearly visible (figure 3).
• He had improper buccolingual inclination as most of the posterior teeth had excess lingual inclination (figure 4).

These three criteria accounted for a reduction in available tongue space, which delivered posterior displacement of the tongue. This condition can result in a negative effect on the patient’s breathing and sleeping.

Diagnosis

Everything added up to a diagnosis of maxillary deficiency, which had an adverse effect on the position of the mandible. The patient’s narrow, underdeveloped maxilla also trapped his mandible in a retruded position upon closure.

Treatment planning

Again, the above diagnostic information was taken into consideration during the consultation process. Since the patient had both foundation and tooth alignment issues, it was determined that he would benefit from a treatment plan addressing both issues. An upper removable expansion appliance would be a good choice to start; however, this patient knew he would not be able to achieve the compliance necessary for the appliance to be effective. Fortunately, clear aligners offer an excellent opportunity for arch development, tooth alignment, and a healthy occlusion.

Micro-osteoperforations

Since my goal was to open the premolar extraction sites, we decided to use the Excellerator Series drivers (Propel Orthodontics) for micro-osteoperforations (MOPs) as a supportive technique to stimulate the patient’s biology. When anatomical issues delay tooth movement longer than is considered normal, productive, or within the patient’s expectations, or the patient has expressed issues with long-term compliance, MOPs are an essential part of the treatment plan.

Without any additional compliance needed from the patient, MOPs can accelerate the rate of orthodontic tooth movement by up to 62% via a microinvasive delivery. The technique can be targeted to certain areas, allowing for total clinical control and predictable, fast tooth movement. The patient agreed to clear aligners with MOPs after a full discussion of all options, including the risks and benefits of each.

Three-step process including integration of MOPs

A digital scan was taken, and a clear aligner case was developed using an expansive technique to develop both arches, including the opening of the premolar sites.

At the next appointment, attachments were placed, the first set of aligners was delivered, and the first round of MOPs was performed with topical anesthetic. Radiographs were used to determine where the MOPs would be performed, with the focus being only on the buccal and lingual of the missing premolar sites (figure 5).

Only a few micro-osteoperforations are needed to create an elevated inflammatory response that leads to better and faster bone remodeling.

The patient was seen at 12-week intervals, and the MOPs were repeated at 12 and 24 weeks. He wore 26 aligners total, with no need for additional aligners (figure 6).

The clear aligners and MOP treatment delivered full-arch development, alignment of the teeth, and a healthy, protective occlusion. At the end of treatment, the transverse measurement was 36 mm, which represents a total of 8 mm of maxillary expansion. The extracted premolar sites have been fully developed and are ready for implant reconstruction (figure 7).

The patient now has proper arch form, proper arch width, and proper buccolingual inclination. Also, the tongue has an increased amount of oral cavity volume, which is always beneficial for airway health.At this point, I referred the patient to Dr. Evan Kantor, a periodontist in Mount Kisco, New York, to place the implant fixtures. Both implants were placed

without the need for bone grafting techniques (figure 8). The implants were uncovered by Dr. Kantor after three months of healing and confirmed integration. My partner, Dr. Gene Goetz, fabricated the restorations for this patient. He placed the two cementable crowns on screw-retained custom abutments (figure 9).

At the completion of treatment, the patient achieved maxillary development, tooth alignment with occlusal coordination, and neuromuscular harmony. The lower arch was expanded and aligned accordingly (figure 10). The result was a healthy, stable, functional, and comfortable occlusion (figure 11), as well as a full display of the teeth when smiling (figure 12). The patient is now four years’ posttreatment, and he remains in this healthy state (figure 13). He has continued

to wear his retainers every night during this time.

If I treated this patient today...

If I treated this patient today, I don’t believe I would have repeated the MOPs. Instead, I may have combined MOPs with VPro (Propel Orthodontics) for the most effective results. High-frequency vibration with the VPro Series has been shown to reduce treatment time by up to 64%. These devices also reduce treatment

discomfort, increase case predictability, optimize aligner seating, and reduce the need for additional aligners. Five minutes of “pulsation” per day has been shown to reduce orthodontic discomfort by releasing the pain receptors that reduce inflammatory pressure.Expansive orthodontics combined with MOPs and VPro technologies is the perfect treatment combination to address patients’ clinical and lifestyle demands. Aside from improved patient comfort and fewer dental visits to achieve desired outcomes, office economics is positively affected. Less chair time yields greater profitability. Given the economic toll COVID-19 has taken on

dental practices, we believe this is a timely win-win scenario for the patient and the practice. We rely on these types of technologies to provide the highest caliber of patient care, experience, and comfort to deliver healthy, beautiful “Zoom-worthy” smiles.

Editor's note: This article appeared in the August 2021 print edition of Dental Economics.

Ben Miraglia, DDS, a graduate of the State University of New York at Buffalo School of Dental Medicine, has practiced general dentistry for 26 years in Mt. Kisco, New York, including 16 years of interceptive orthodontics with a focus on early childhood growth and development. An international lecturer, he is on the Align Technology faculty, the American Academy of Physiological Medicine and Dentistry Board of Directors, the Northern Westchester Hospital President’s Council, and is vice president of clinical affairs for Airway Health Solutions.

Lauren Gueits, BS, RDH, is CEO and founder of Airway Health Solutions and Clear Aligner University. A 1991 graduate of the State University of New York at Farmingdale, she received postgraduate training in myofunctional therapy from the Academy of Orofacial Myofunctional Therapy in 2013. She is guest faculty at New York University, a key opinion leader/national speaker, and a recipient of the 2010 Sunstar/RDH Award of Distinction. Gueits is an advocate for airway health and early interceptive/expansive orthodontics.