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Inside Dentistry
April 2023
Volume 19, Issue 4
Peer-Reviewed

Anterior Intrusion With Clear Aligners

Restoring a deep Class II bite without compromising function and esthetics

Andrew Ferris, DDS, MS

Deep bites, which are very commonly seen in practice, can develop for a number of reasons, but oftentimes, patients present with a lack of coupling due to a Class II dental or skeletal malocclusion. This can result in super eruption of the anterior teeth and create challenging situations for clinicians. Research shows that deep bites can cause pathway interferences due to a restriction in the envelope of function, which can lead to accelerated attrition. Deep bites can also increase the load on the temporomandibular joints and affect overall function. Although there are several treatment options that can be presented to these patients, including traditional orthodontics, clear aligners can be an effective appliance to correct this type of malocclusion when correctly designed.

Case Report

A 57-year-old female patient presented to the office with severe malocclusion. She had a deep bite of greater than 100% that was impinging on the palate as well as severe crowding in her anterior mandible. In addition, she had a multitude of other health conditions, including severe intraoral scarring due to prior ingestion of a caustic substance. An initial cone-beam computed tomography (CBCT) scan was acquired during the examination.

Developing an orthodontic treatment plan was challenging due to the patient's severe amount of mandibular crowding and severe two-plane occlusion. It would have been easy to justify premolar extractions; however, she was brachyfacial, and this approach would have compromised her function and the appearance of her profile. Furthermore, the use of traditional fixed appliances would have been very challenging in this situation due to the severe two-plane occlusion and crowding. The path of least resistance would be in the anterior direction, which could result in severe proclination and compromise the incisors. Therefore, clear aligner treatment (Invisalign®, Align Technology) was used to fully intrude the lower anterior teeth while developing the arch forms in order to create space to align the teeth and finish with a healthy functional occlusion. The treatment was enhanced by daily use of a device that delivers micropulsed vibrations to accelerate tooth movement (AcceleDent Aura®, OrthoAccel Technologies, Inc).

During treatment, the patient decided to purchase a low-level laser therapy device online and switch aligners every five days to further accelerate the treatment. Although this was not recommended, within less than 6 months, her lower anterior teeth had intruded approximately 6.6 mm. This shows how powerful clear aligners can be as a tool, even in treating the most complex cases.

The final result of intruding the lower incisors was a level occlusal plane. A final CBCT scan was acquired and compared with the initial CBCT scan, and measurements were made from the incisal edges of the mandibular anterior teeth to the border of the mandible and from the occlusal surfaces of the premolars to the border of the mandible. After 50 weeks of treatment, the mandibular incisors had been intruded by approximately 8 mm with insignificant extrusion of the posterior teeth. As a part of the treatment, teeth Nos. 24 and 25 were differentially intruded in order to create the space necessary to restore the exposed dentin, and a lingual wire (Retainium, Reliance Orthodontic Products) was placed in the anterior mandible for retention. The patient continued to follow-up over the next 5 years to ensure stability.

About the Author

Andrew Ferris, DDS, MS
Lecturer, Orthodontics
Loma Linda University
School of Dentistry
Loma Linda, California
Private Practice
Santa Barbara, California

Pretreatment full-face patient portrait.

Figure 1

Pretreatment full-face patient smile portrait.

Figure 2

Pretreatment panoramic radiograph showing the two-plane occlusion.

Figure 3

Pretreatment right profile patient portrait and pretreatment cephalometric radiograph showing a lack of lower lip support and a Class II dental and skeletal relationship.

Figure 4

Pretreatment right profile patient portrait and pretreatment cephalometric radiograph showing a lack of lower lip support and a Class II dental and skeletal relationship.

Figure 5

Pretreatment retracted photograph showing the severe deep bite.

Figure 6

Pretreatment retracted righ and left lateral photographs showing the amount of overbite and overjet.

Figure 7

Pretreatment retracted righ and left lateral photographs showing the amount of overbite and overjet.

Figure 8

Pretreatment retracted photograph with the teeth apart showing the severe two-plane occlusion.

Figure 9

Pretreatment upper and lower occlusal view photographs showing the severe level of crowding, especially in the lower anterior region.

Figure 10

Pretreatment upper and lower occlusal view photographs showing the severe level of crowding, especially in the lower anterior region.

Figure 11

Progress photograph acquired after 6.5 months of clear aligner treatment demonstrating that the lower anterior teeth had been intruded by approximately 6.6 mm.

Figure 12

Posttreatment retracted photograph.

Figure 13

Posttreatment retracted photograph with the teeth apart showing the leveling of the occlusal plane and differential intrusion of teeth Nos. 24 and 25 in preparation for restoration to cover exposed dentin.

Figure 14

Posttreatment right and left lateral photographs. Note that the left lateral view shows less than complete correction, but the patient expressed that she was happy with the result.

Figure 15

Posttreatment right and left lateral photographs. Note that the left lateral view shows less than complete correction, but the patient expressed that she was happy with the result.

Figure 16

Posttreatment upper and lower occlusal view photographs. Note the lingual wire that was placed in the lower anterior region for retention.

Figure 17

Posttreatment upper and lower occlusal view photographs. Note the lingual wire that was placed in the lower anterior region for retention.

Figure 18

Posttreatment panoramic radiograph demonstrating that the lower anterior teeth were intruded by approximately 8 mm. Note the slight root blunting of the lower anterior teeth that occurred as a result of their intrusion.

Figure 19

Posttreatment cephalometric radiograph showing increased proclination of the lower anterior teeth.

Figure 20

Posttreatment right profile patient portrait.

Figure 21

Posttreatment right oblique patient portrait.

Figure 22

Posttreatment full-face patient portrait.

Figure 23

Posttreatment full-face patient smile portrait.

Figure 24

Andrew Ferris, DDS, MS

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