Clear Aligners - An efficient tool in the.pptx

Clear Aligners - An efficient tool in the.pptx

1. Clear Aligners - An efficient tool in the combined Ortho- Perio treatment of gingival recessions Seminar may 2024

2. Gingival recession (GR) is defined as the apical migration of the marginal gingiva away from the cementoenamel junction (CEJ), leading to the exposure of the root surface to the oral environment. more frequently on buccal surfaces. Distribution of buccal GRs undergoes age-related changes, initially impacting the upper first molars and premolars, with a shift towards a higher occurrence in the incisors and canines Etiology: chronic trauma (by vigorous brushing, periodontal disease, periodontal treatment, and occlusal trauma). Predisposing factors: thin gingival biotype, reduced alveolar crest thickness, dehiscence and fenestration, and atypical frenal attachment GRs of lower incisors: trauma (brushing, piercing), bacterial induced inflammation and root malposition in the alveolar bone, previous orthodontic treatment GR is caused by a distorted, malfunctioning fixed retainer. It generates torsional forces that displace a connected tooth root beyond the envelope of the alveolar process

3. Classification of GR severity and its posttreatment prognosis ( PD.Miller ) based on the positioning of the gingival margin in relation to the mucogingival junction and the underlying alveolar bone level Class I and Class II: Mildest, exhibit no loss of interdental bone or soft tissue, achieving complete root coverage by surgical means is relatively predictable. (The difference between these two classes is the presence or absence of attached gingiva Class I recession was originally described as recession that does not extend to the MGJ), if the gingiva is unattached, there is “hidden recession,” and this is actually a Class II recession) Class III GR :loss of both interdental bone and soft tissue, usually allowing only partial root coverage following surgical procedures. Class IV GR: most severe category, where achieving root coverage becomes almost impossible due to the total absence of interdental papilla

4. Orthodontic intervention as a supportive measure for GR treatment: soft tissue augmentation prior to orthodontic tooth movement after orthodontic root repositioning. wider the root exposure, the poorer is its prognosis of complete root coverage (CRC) correction of root inclination reduced the GR severity Orthodontic treatment with clear aligners lingual root tip was, in general, significantly less accurate than labial crown tip, particularly for the maxillary incisors aligners without modifications: limited potential to induce bodily movement or torque control of teeth aligner modifications (attachments, pressure points, or different aligner geometries): might increase the efficacy of tooth translation or torque movement. Furthermore, adequate staging can increase the accuracy of torque control ( Regarding the treatment protocol of Align technology, velocities up to 2 degrees/aligner for rotation, up to 1 degree/aligner for incisor torque and up to 0.25 mm/aligner for distalization are possible.)

5. Case report 1 GR on the buccal side of the lower right central incisor (#41) after completion of orthodontic treatment. Miller Class I GR along with mild gingival inflammation around the GR margins. Root was displaced buccally, as revealed by the frontal view and by palpation at the clinical examination, presence of a distorted fixed lingual retainer and a mild lingual displacement of the adjacent root of the lower left central incisor (#31). ClinCheck plan incorporated an over-correction strategy, it involved introducing a 19° lingual root torque for tooth #41 and a 9°degree buccal root torque adjustment for tooth #31. An overcorrection of 2−3° was arbitrarily added in the last aligners.

6. Case report 2 Miller Class II gingival recession and associated gingival inflammation a mild anterior open bite on the right side, a distorted fixed lingual retainer, which had probably induced labial root displacement of the lower right central incisor #41 and minor lingual root displacement of the lower left central incisor (#31) ClinCheck plan incorporated an over-correction strategy for the root positions of teeth #41 and #31, with a 10° lingual root torque for tooth #41 and a 9° buccal root torque for tooth #31. the change in root inclination was quantified using the CBCT sagittal views, by calculating the difference between the initial position and the ideal root position in the middle of the alveolar bone. On completion of the orthodontic treatment, the patient was referred to a periodontist (AS) for surgical coverage of the residual root exposure by surgical method chosen was laterally moved, coronally advanced flap

7. Case report 3 , a Miller Class II severe GR was observed on the lower right incisor (#41) with considerable plaque accumulation and gingival inflammation. The lower left incisor (# 31) exhibited a less severe Miller Class II GR and slight open bite cause of the labial roots’ displacement was a distorted fixed lingual retainer and presence of an incisal insertion of the labial frenum two sets of aligners were given Frenectomy was performed after completion of the first set of aligners surgical procedure into two steps. 1. a laterally moved coronally advanced flap surgery was used to exclusively cover the right central incisor 2 . coronally advanced flap, aiming to achieve coverage of both lower incisors

8. Discussion Clear aligners are effective in repositioning lower incisor roots the effectiveness of aligners in lingual root torquing of lower incisor roots, in contrast to the low predictability reported for palatal root torquing of upper incisor (different anatomical characteristics of the lower incisors’ roots, which are shorter and slender in comparison to other teeth) confinement of the roots within the bony boundary significantly improved the GR. the shift of the root towards the lingual side enhances the blood supply to the thin overlying gingiva, supporting the restoration of its thickness. Aligner design and treatment planning ( ClinCheck ) first step in planning is to determine the amount of root torque needed, which can be calculated from the CBCT sagittal views. A Power Ridge feature should be incorporated at the cervical part of the aligners, to generate the required lingually directed force. aligners must be elongated as much as possible to fully cover the cervical part of the root and thus transfer the force closer to the center of resistance Overcorrection should be included in the last aligners, which should be limited only to movement of the affected tooth, after correcting all the other aspects of malocclusion. Several roots need repositioning in the same direction, mostly lingually, a good strategy is moving the displaced roots one by one while defining the anchor teeth as “unmovable”

9. Advantages of using clear aligners in treating GR repositioning of incisor roots allow precise control over which teeth move enabling the clinician to focus each time on a specific tooth, while using the non-moving other teeth as anchorage allows initiating the root repositioning from the very first aligner, self-limiting nature of the clear aligners system. root repositioning phase using aligners with that of fixed appliances, the outcomes were remarkably similar Disadvantages Treatment duration was identical to fixed appliances patient’s ability to remove them Non-compliance in wearing