Clear aligners are increasingly the treatment of choice over traditional fixed appliances for adult patients looking for improved aesthetics and comfort.[i]
They have been found to improve upon a patient’s psychosocial, physical pain and physical/psychological/social disabilities when compared to traditional orthodontic devices.[ii] Where appropriate, clinicians might well hope to offer their patients the choice to experience these benefits, including in the most complex cases.
Completely understanding the potential applications for clear aligners, as well as their limitations, allows clinicians to tailor their advanced treatment plans according to their patients’ unique needs, and provide this often-preferred form of care in more cases.
Material matters
To use clear aligners to their greatest potential, it’s important to look briefly at their treatment ceiling. Complex cases that include severe bite issues, large gaps, or severe crowding may make this form of treatment less suitable, instead requiring traditional fixed braces.[iii] The literature has also cited distalisation, rotation and extrusion as some of the more difficult movements to carry out successfully with clear aligners,[iv] and whilst it is not impossible to achieve these results, a relevant case may prompt the need for an alternative treatment approach.
However, recent developments in the materials used to create clear aligners as well as clinical approaches have improved predictability in a wider range of cases.
Polyethylene terephthalate glycol (PETG) materials have been the solution of choice for many complex designs due to their durability, high impact strength and resistance to chemical changes.[v] With impressive mechanical and optical properties, it’s easy to see why they are increasingly preferred. v
The future of complex clear aligner cases could lie in shape memory polymers (SMPs), sometimes known as actively moving polymers. This material offers the ability to revert to an original shape when achieving a necessary transitionary trigger, such as a certain temperature for a designated time period. During a treatment cycle, the SMP-based aligner could be subjected to such a trigger, reverting to a predefined shape, and in turn generating forces which can produce orthodontic tooth movement. v When designed to harbour multiple aligner shapes within its form, it could reduce the number of aligners used during orthodontic treatment and achieve complex corrections sooner. v
Step by step
When tackling a complex case suitable for aligner therapy, treatment is most effective when the dentist creates an efficient and actionable treatment plan. Therefore, one of the most important skills for a clinician providing clear aligners for complex cases is an understanding of how to implement staging.
Those that have prior experience in orthodontics may know that staging refers to the breakdown of an intended movement of teeth in a sequential manner, with the use of aligners.[vi] This segmented approach allows for the close control over linear and rotational movements over time, with each new aligner achieving a specific step that gets a patient closer to their end goal. In complex cases, staging orthodontic tooth movement is essential and can be used to attain better treatment outcomes. vi
When used in the treatment of severe crowding, staging has provided no significant differences in results when compared to fixed brace treatments, including in case duration. i One 2022 study i broke up the process into three overarching stages of ‘decrowding‘, ‘space closure’ and ‘fine-tuning’. This allows for targeted movement of the crowded anterior teeth, before achieving a class I canine and molar relationship, and making final adjustments, such as overcorrections – recommended by many in case of possible relapses iv – and closures of any residual spaces.
Segmented approaches also allow clinicians to focus on moving just one or several teeth at a time, which is useful throughout a treatment sequence, and help to minimise proclination that may result from fixed brace treatment. [vii]
Clinical confidence
There are always going to be some cases where fixed appliances have an irrefutable advantage over clear aligners. The key is recognising these, and when a suitable case presents, enacting a treatment plan that allows for success within the patient’s preferences, which may well be with the more aesthetically pleasing clear aligners.
To do so, clinicians could embark on the Clear Aligner (Level 2) course from IAS Academy, which is specifically designed to equip clinicians with the skills to take on more complex cases and expand their patient base. The course provides insight on case selection, treatment planning with a variety of clear aligner systems, accurate staging, interproximal reduction, and so much more. Plus, delegates can receive guidance long after the course has ended with the renowned mentoring from IAS Support, so they can confidently provide clear aligner therapy in the coming years.
Clear aligner orthodontics has experienced immense progression in tandem with heighted patient demands. Now, with the right materials and approaches to care, clinicians can help more patients with a greater complexity of treatment needs. With a trained eye for case suitability and the skills to devise an effective treatment plan, predictable results are well within reach.
For more information on upcoming IAS Academy training courses, please visit www.iasortho.com or call 01932 336470 (Press 1)
Author Bio:
Dr Tif Qureshi founder and a clinical director of IAS Academy
[i] Jaber, S. T., Hajeer, M. Y., Burhan, A. S., & Hajeer, M. Y. (2022). The effectiveness of in-house clear aligners and traditional fixed appliances in achieving good occlusion in complex orthodontic cases: a randomized control clinical trial. Cureus, 14(10).
[ii] Ben Gassem, A. A. (2021). Does clear aligner treatment result in different patient perceptions of treatment process and outcomes compared to conventional/traditional fixed appliance treatment: a literature review. European Journal of Dentistry, 16(02), 274-285.
[iii] AlMogbel, A. (2023). Clear Aligner Therapy: Up to date review article. Journal of orthodontic science, 12.
[iv] Marcelino, V., Baptista, S., Marcelino, S., Paço, M., Rocha, D., Gonçalves, M. D. P., … & Pinho, T. (2023). Occlusal Changes with Clear Aligners and the Case Complexity Influence: A Longitudinal Cohort Clinical Study. Journal of Clinical Medicine, 12(10), 3435.
[v] Bichu, Y. M., Alwafi, A., Liu, X., Andrews, J., Ludwig, B., Bichu, A. Y., & Zou, B. (2023). Advances in orthodontic clear aligner materials. Bioactive Materials, 22, 384-403.
[vi] Mehta, S., Patel, D., & Yadav, S. (2021). Staging orthodontic aligners for complex orthodontic tooth movement. Turkish Journal of Orthodontics, 34(3), 202.
[vii] Ke, Y., Zhu, Y., & Zhu, M. (2019). A comparison of treatment effectiveness between clear aligner and fixed appliance therapies. BMC Oral Health, 19(1), 1-10.
