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Compendium
October 2020
Volume 41, Issue 9

How Is Digital Treatment Planning in Conjunction With Clear Aligners Impacting Interdisciplinary Care?

Marc L. Alexander, BSc, BChD (hons), DDS; Marc H. Bienstock, DDS, MD and Drew Ferris, DDS, MS

Dr. Alexander

The use of clear aligner therapy in the prosthodontic process offers numerous advantages. Perhaps the greatest impact clear aligner therapy has had on interdisciplinary care is in the area of case acceptance. Prosthetic rehabilitations often require and benefit from orthodontic correction to enhance functional and esthetic outcome. Most, but not all, of these patients are adults. In my experience, patients who require rehabilitation, whether an esthetic veneer restoration or a complex comprehensive reconstruction, are far more willing to accept aligner therapy as part of their treatment than fixed appliance orthodontics.

The practitioner performing aligner therapy must be knowledgeable of its mechanics, including its potential, challenges, and limitations. Moreover, the treatment team must be in full control of the case prescription. Clear, specific treatment goals and expected outcomes need to be communicated before clinical treatment is initiated. Patient compliance is crucial to a timely outcome.

Patient education with an emphasis on motivation to receive orthodontic therapy is a major part of case acceptance. Digital capture of the existing dental condition shown alongside a digital projection is a powerful patient communication tool and motivator. Communicating with the patient in a visual medium can be highly impactful. This aspect is also advantageous for provider interdisciplinary case treatment planning. The ability for the team to plot out guidelines, goals, staging, and individual participation practices ahead of treatment aids in the efficiency and success of care.

Force management is a critical factor in case longevity and success. Control of occlusal scheme and elimination of adverse loads and interferences is essential. Pre-prosthetic orthodontics is integral in this control. Without the orthodontic correction, overpreparation of teeth often is required and often may not allow ideal correction. The caregiver must do no harm. Conservation of tooth structure is vital to the long-term health of the dentition.

Correction of tooth size, Bolton discrepancies, and proportions is required to achieve an ideal class I occlusion, occlusal scheme, and esthetic outcome, especially in orthognathic cases. Pre-orthodontic tooth size correction, provisional fabrication, and sometimes mid-orthodontic resin bonding to idealize tooth size are advised to aid in efficient alignment. With aligner therapy mid-treatment correction can be easily adjusted with a rescanning and revision.

Teenaged patients with congenitally missing teeth increasingly appear to be asking for aligner therapy over fixed appliances. In these cases, goals of therapy should be to idealize occlusion, preserve teeth, and set the patient up for adulthood with an optimal occlusion in mind.

Within our disciplinary team, patients with complex and severe malocclusions are treated with aligner therapy, which is a well-accepted treatment modality. To achieve success, the use of temporary fixed anchorage is often needed. Surgical temporary anchorage devices and occasionally conventional implants may need to be placed to allow complex challenging movements to occur. The digital workflow, utilizing comprehensive step-by-step tooth movement planning, allows for easier prediction of ideal implant placement before orthodontic treatment is initiated. Also, the use of surgically facilitated orthodontic therapy may expedite complex movements and enhance the bony and soft-tissue housing.

In conclusion, interdisciplinary care with aligner therapy can increase case acceptance, case outcome, and success. While similar outcomes may be attainable with fixed appliance care, the digital realm helps clinicians achieve improved efficacy in communication, more timely treatment, and enhanced execution with multidisciplinary tools and team collaboration.

Dr. Bienstock

In this age of "digital dentistry" there are many advances in technology that positively impact both the doctor and patient experience throughout treatment. Interdisciplinary teams have evolved to be at the forefront for treatment of complex dental cases. Ultimately, like any highly functional team, communication among team members is essential to the ultimate success of the treatment.

Digital technology, and in particular clear aligner therapy, allows the whole treating team to understand the patient's progress and status throughout the course of treatment. Phasing care through a detailed stepwise approach is often necessary to accomplish intermediate goals throughout. Aligner therapy sets the backdrop for establishing a timeline that can be communicated with the patient to set appropriate treatment goals and help the clinicians schedule out future appointments.

The newest digital technology that I have incorporated into my everyday practice is a dynamic navigation surgery system (X-Guide®, X-Nav Technologies, x-navtech.com). The "dynamic" implant guide has forced me to convert my mind frame from analog to digital. In short, every implant is planned in a digital CAD planning software. This planning requires the combination of a CBCT, intraoral digital impression, and idealized digital virtual wax-up. Once everything is appropriately overlaid in the planning software, the implant can be positioned in the most idealized location. With this "imported" information, both the planning and execution of surgically placing the implant is extremely accurate. The digital information I utilize comprises a combination of bone volume and location, but most importantly, the planned implant's position can easily be prosthetically driven. Nowhere in this process is it necessary to jump back into the analog workflow.

Aligner therapy has emerged as a tool for the predictable movement of teeth that offers many advantages when dental implants are part of a complex treatment plan. In the early days of aligner therapy, it became obvious that utilizing the proprietary software (ClinCheck®, Align Technology, invisalign.com) as a "guide" allowed clinicians to "predictably" place implants earlier in the treatment sequence, because it was not necessary to wait for final tooth movement. As clinicians became more comfortable with this concept, they began placing implants in their "proposed" position utilizing the aligner software and calculating future movements in order to know where implants ultimately would be needed. Now this can be done by importing information obtained from the aligner software into the navigation system software to predict final tooth position. Besides shortening the overall length of treatment due to earlier integration of implants, this approach allows the orthodontist to more efficiently move teeth by utilizing the integrated implants as anchorage.

As these various platforms continue to be assimilated, clinicians' ability to shorten treatment times and predictably accomplish treatment goals will only improve.

Dr. Ferris

The evolution of clear aligner treatment has changed the practice of orthodontics. Personally, it has allowed me to transition my office from an analog to digital platform, which has positively impacted case acceptance, clinical outcomes, patient experience, and profitability. No longer is clear aligner treatment reserved only for mild orthodontic correction. Some of my most challenging orthodontic cases have been completed with aligner therapy, with better and more efficient results than I believe would have been achieved with traditional fixed appliances.

Adults with multi-specialty concerns are often the most difficult cases. Interdisciplinary treatment from a team of specialists is needed to provide adequate quality of care and optimal outcomes for such patients. I utilize an end-to-end digital platform (Align Technology, Inc., aligntech.com) for efficient diagnosis and treatment planning processes as well as patient education and case execution.

The ability to manipulate teeth in the three planes of space using iTero® scanner software and ClinCheck® software enables the creation of a "virtual wax-up" and sets the foundation for the rest of the interdisciplinary team. An intraoral scanner (iTero Element®) is the centerpiece for digital treatment. I am able to scan new patients, use the scanner's simulator feature to educate and treatment plan, and then transfer the file to the other members of the team. I often sit with my restorative dentist (either in person or virtually) to digitally position the teeth in the software, creating an end point or target for the teeth for ideal restoration.

From this point, I design a "roadmap" in ClinCheck that will efficiently bring us to that end point. Mid-treatment, it is no longer necessary to send the case back to the restorative dentist to ask if he or she thinks we have arrived at that end point yet. Rather, I can take a new scan and with the iTero software, digitally superimpose our goal and current position. Mid-treatment assessment serves the patient by validating that, indeed, progress to the goal is actually tracking. It also keeps the team informed regarding treatment progress. I am also able to collaborate with the surgeon and transfer my STL file to his or her software to place implants early in treatment so they can be used as anchorage for proper tooth movement.

These digital technologies enable 3-dimensional control and positioning of the teeth, laying the framework for the rest of the team. In addition, a hybrid dental imaging system (iTero Element 5D) visualizes caries through the use of near infra-red imaging (NIRI), allowing us to refer back to the dentist and help maintain the patient's overall oral health. This helps orthodontists build trusting partnerships with their restorative dentists as they become aware of patients' restorative needs, and thus referrals become more reciprocal.

With aligner therapy, orthodontics has expanded well beyond children and teenaged patients as adults and their dentists become increasingly aware of the importance of a functional bite and aligned dentition and that this therapy is not just for esthetic purposes. The clear esthetics of aligner treatment and the ability to visualize the projected end result help increase case acceptance.

Disclosure

Dr. Ferris is a consultant for Align Technology, Inc.

Marc L. Alexander, BSc, BChD (hons), DDS

Retired Associate Professor of Clinical Dentistry, University of Southern California School of Dentistry; Private Practice in Prosthodontics, Santa Barbara, California

Marc H. Bienstock, DDS, MD

Diplomate, American Board of Oral and Maxillofacial Surgery; Private Practice in
Oral and Maxillofacial Surgery,
Santa Barbara, California

Drew Ferris, DDS, MS

Lecturer, Orthodontics, Loma Linda University School of Dentistry, Loma Linda, California; Director, Santa Barbara Dental Study Group; Private Practice in Orthodontics,
Santa Barbara, California

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