Aligner can correct cross-bite, open-bite, overbite under-bite, crowding, and spacing & proclined teeth.

Cross bite

A cross bite occurs when the top & bottom jaws simply do not meet up properly due to lateral misalignment of the upper & lower arches. It is usually characterized by some of the top front teeth sitting inside the front lower teeth. Cross bites almost always require orthodontic treatment because they can cause major issue like gum recession, bone loss or cracked tooth.

Open bite

An open bite occurs when the top & bottom jaws do not meet up at all. In cases of open bite, there is generally gap between the top and bottom teeth. As you can probably guess, this makes biting and chewing    highly difficult. By closing your bite through aligner orthodontic treatment .your dentist will close the bite and restore proper chewing function.

Overbite

An overbite or deep bite occurs when the top front teeth overlap the bottom front teeth by more than 25%.Many people have a slight overbite that is known as class 1 malocclusion. However, cases over 25% are known as class 2 malocclusion or retrognathism & usually require corrective treatment to prevent future jaw pain & premature tooth wear.

Under-bite

An under bite is basically an overbite reversed with an under bite, the lower front teeth overlap the top front teeth because the lower jaw is too far forward. Under bite is also knowns as prognathism & are considered as a class III malocclusion. They often make it difficult to chew & speak properly & may also wear down the teeth. For these reasons dentist recommended orthodontic treatment to resolve an under bite. While aligner can treat under bite. Severe cases may also require surgery in coordination with aligner treatment.

Crowding of teeth

When there is not enough room in the jaw to accommodate all of your teeth, they can overlap and twist, this is known as crowding. The reduced space between teeth allows for food to become stuck and for tartar and plaque to build up which may contribute to tooth decay and gum disease. Aligner can treat cases of crowded teeth depending on the severity and complexity of the problem.

Spacing in teeth

If there is a gap between two or more teeth, this is called as spacing. In excess space food accumulate between teeth and gums, causing pain and gum disease. Aligner can close the gap to create a healthier mouth and more aesthetic smile.

Proclined teeth can also be correct by the aligner treatment.

The patient chief complaint should be recorded in his or her own words. It helps the clinician in identifying the desires and priorities of the patient.

Most patients seek orthodontic care for reasons of either aesthetics or impaired function. In many patients the impairment of the aesthetic by way of malocclusion may lead to psychological problems and therefore the patient may seek orthodontic treatment to improve the quality of life.

The chief complaint can be elicited by way of an interview or by asking the patient to fill in a questionnaire.

There are two type

Soft tissue examination

Hard tissue examination

Soft tissue examination-

1.    Gingiva- Anterior marginal gingivitis usually occurs in mouth breathing and open mouth habit. While generalized marginal gingivitis is associated with poor oral hygiene.

2.    Frenum – A persistent and thickened labial frenum may be present in 25% of children at age of 8 years.

3.    Palate – should be examined by palpation and visually. Asymmetrical contour are usually caused by unerupted teeth.

4.    Tongue – is a powerful combination of muscles around which dentition is shaped and molded.

      Its size: large tongue cause generalized diastema.

      Its action: forward positioned tongue causes open bite, backward positioned tongue may cause anterior crowding.

Hard tissue examination –          

1.    Number of teeth

Teeth present & erupted

Teeth present & unerupted

Extracted teeth

Congenitally missing teeth

Extra teeth

2.    Condition of teeth

Carious or sound

Non-vital or vital

Teeth with extensive restoration

Broken teeth

Malformed or fused teeth

3.    Proportion of tooth size to arch size

           Crowding occurs where teeth are large compared to jaw size.

4.    Position of teeth

      Any of individual teeth malposition.

5.    Malposition of individual teeth 

Labioversion

Supraversion

Mesioversion

Torsoversion

Linguoversion

Infraversion

Distoversion

Transversion

6.    Malrelation of  the dental arches

Anteroposterior malrealtionship

·       Class 1

·       Class 2

-      Division 1

-      Division 2

-      Class 3

Vertical malrelationship

·       Deep overbite

·       Edge to edge bite

·       Open bite

·       Transverse malrelationship

7.    Posterior cross bite( unilateral bilateral or telescoped bite)

8.    Midline shift

Extra oral Examination

A.        Shape of head-

Mesocephalic – Average shape of head. They possess normal dental arches.

Dolicocephalic-long & narrow head. They have narrow dental arches.

Brachycephalic- Broad and short head. They have broad dental arches.

B.        Facial form –

Mesoprosopic- it is an average or normal face form.

Euryprosopic- This type of face is broad & short.

Leptoprosopic- It is long & narrow face form.

C. Facial profile –

The profile is determine by joining the following two reference lines-

A line joining the forehead & soft tissue point a (deepest point in curvature of upper lips)

A line joining point A & the soft tissue pogonion (most anterior point of chin)

Based on relationship between these two lines three type of profile exist.

Straight profile- The two lines form a nearly straight line.

Convex profile- The two lines form an angle with the concavity facing the tissue. This kind of profile can occurs as result of prognathic maxilla or a retro gnathic mandible as seen in a class 2, division 1 malocclusion.

Concave profile- The two reference lines form an angle with the convexity towards the tissue. This type of profile is associated with a prognathic mandible or retro gnathic maxilla as in class 3 malocclusion.

D. Facial Divergence – Facial divergence is defined as an anterior or posterior inclination of the lower face relative to the forehead. Facial divergence can be of three types:

Anterior divergent: A line drawn between the forehead and chin is inclined anteriorly towards the chin.

Posterior divergent:  line drawn between the forehead and chin slants posteriorly towards the chin.

Orthognathic:  line between the forehead and chin is straight or perpendicular to the floor.

E. Examination of lips – Normally the upper lip covers the entire labial surface of upper anterior except the incisal 2-3mm. The lower lip covers the entire labial surface of the lower anterior and 2-3mm of the incisal edge of the upper anterior. Lips are classified into four types:

Competent lips: The lips are in slight contact when the musculature is relaxed

Incompetent lips: They are morphologically short lips that do not form a lip seal in a relaxed state. The lip seal can only complete by active contraction of the perioral and mentalis muscle.

Potentially incompetent lips: They are normal lips that fail to form a lip seal due to proclined upper incisors.

Everted lips: They are hypertrophied lips with weak muscular tonicity.

F. Examination of nose –

Nose size: Normally the nose is one third of the total facial height (from hair line to lower border of chin.)

Nasal contour: The shape of nose can be straight, convex or crooked as a result of nasal injuries. 

Nostrils: They are oval and should be bilaterally symmetrical. Stenosis of the nostrils may show impaired nasal breathing.

G. Examination of chin –

Mento-labial sulcus: The mento-labial sulcus is a concavity seen below the lower lip. Deep mentolabial sulcus seen in class 2, division 1 malocclusion while it is shallow in bimaxillary protrusion.

Mentalis activity: Normally the mentalis muscle does not show any contraction at rest. Hyperactive mentalis activity is seen in some malocclusion such as class 2, division 1 cases. It causes puckering of the chin.

Chin position and prominence: Prominent chin is usually associated with class 3 malocclusion while recessive chins are common in class 2 malocclusion.

Yes, OPG & lateral cephalogram is must for every case of aligner.

OPG – Orthopantomogram is one of the most popular records in orthodontics diagnostic phase, it provides important bilateral dental and skeletal information. Panoramic radiographs provides information of the number of teeth present, Eruption problems, root form & length, quality of alveolar bone and other pathological conditions, it  is also taken during treatment to check the parallelism of the roots and the presence of root resorption It also shows chronology of human permanent dentition, loss of space preventing the lower premolars from erupting also showing mandibular third molar fused with supernumerary tooth.It also provides limited information about gross periodontal health, sinuses, mandibular symmetry and the TMJ.

Lateral cephalogram –Lateral cephalogram is used primarily in orthodontic diagnosis and treatment planning, particularly when considering orthognathic surgery.it is useful record to prior to treatment and can be used during treatment to assess progress. It is used to assess the etiology of malocclusion to determine whether the malocclusion is due to skeletal relationship, dental relationship or both. Once taken, the lateral cephalogram should be traced, either by hand or digitally and analysed to help with treatment planning and diagnosis. Some of basic anatomy seen on lateral cephalogram is frontal sinus, Sella turcica , nasal bone, and maxillary sinus, inferior border of mandible, hyoid bone & cervical spine.

The most common indication for CBCT in orthodontics is 3D assessment of anomalies in dental position.CBCT is recommended in cases of cleft palate, craniofacial syndrome, supernumerary teeth, assessment of multiple impacted teeth, identification of root resorption caused by impacted teeth, planning for orthognathic surgery.

Frenal attachment are thin fold of mucous membrane with enclosed muscle fibres that attach the lips to the alveolar mucosa and underlying periosteum. Abnormal frenal are detected visually, by applying tension over it to see the movement of papillary tip or blanch produced due to ischemia of the region. Miller has recommended that frenum should be characterized as pathogenic when it is usually wide or there is no apparent zone of attached gingiva along the midline or the interdental papilla shift   when the frenum is extended.

Blanch test- is used to determine the role of frenum as a causative factor for mid line test.

Step 1 – The lip is pulled superiorly and anteriorly

Step 2 – Any blanching indicates fibers of the frenum crossing the alveolar ridge

An IOPA will show notching in inter dental alveolar ridge region. 

Tongue: is a powerful combination of muscle around which dentition is shaped and moulded.

Large tongue cause generalized diastema & it can corrected by aligners.

Its action forward positioned tongue cause open bite, backward positioned tongue may cause anterior crowding.

When the tongue pressed forward too far in mouth, called as tongue thrust resulting in an abnormal orthodontic condition called open bite.

Treatment for anterior open bite –

1. Attachment of palatal tongue spurs in clear aligners

Anterior open bite is commonly associated with tongue thrust and similar oral habits, which must be addressed during treatment to ensure long term stability.

A tongue thrust habit is traditionally controlled with the use of tongue spurs bonded to the lingual surface of the incisor or soldered onto an appliances such a lingual holding arch.

Technique – During the virtual setup, place two attachments (one on top of the other) on lingual surface of each selected anterior tooth. Remember not to fill the lingual attachments wells with composite while creating the buccal attachments. Before fitting the aligner in the patient’s mouth, sharpen the lingual attachment wells with a scissor blade so they will look and work like conventional metal spurs.

The lingual frenum should be examined for tongue tie. In patients having tongue tie there is an alteration in the resting tongue position as well as impairment of tongue movement.

 In tongue tie due to limited tongue mobility, they have difficulties with speaking eating drinking breathing.

Other common signs of tongue tie includes-

Problems sticking tongue out of mouth past lower front teeth

Trouble lifting your tongue up to touch upper teeth or moving tongue from side to side

Tongue looks notched or heart shaped when stick it out.

Surgical treatment of tongue tie may be needed for infants, children or adult if tongue causes problem. Surgical procedure include a frenotomy or frenuloplasty. 

Frenectomy is simple surgical procedure can be done with or without anesthesia. Doctor examine the lingual frenulum and then uses sterile scissors to snip the frenulum free. The procedure is easy and discomfort to the patient is minimal since there are few nerve endings in the lingual frenulum.

A more extensive procedure known as a frenuloplasty might be recommended if additional repair is needed or the lingual frenulum is too thick for a frenotomy. A frenuloplasty is done under general anesthesia. After the frenulum is released, the wound is usually closed with suture absorbs on their own as the tongue heals.

Laser treatment is non-invasive technique for tongue tie it reduces bleeding and pain.  Dentist use a laser to cut through the connective tissue between the tip of tongue and bottom of their mouth.

Retention protocol in tongue tie- After the aligner treatment Essex/wrap-a-round retainer and lingual bonded retainer should be given.

The consequences of macroglossia usually include a possible malfunction of the stomatognathic system, breathing & speech problem, increased mandible size, tooth spacing diastema & other orthodontic abnormalities.

The major primary factors in the dental equilibrium appear to be resting pressures of tongue and lips, and forces created within the periodontal membrane, analogous to the forces of eruption. Forces from occlusion can disturb vertical position of teeth by affecting eruption. Respiratory needs influence head, jaw and tongue posture and thereby alter the equilibrium. Deviate swallowing is more likely to be an adaptation than cause of teeth.

The dental midline is the line between your two upper front teeth and your two lower front teeth, and it plays significant role in orthodontic treatment. The dental midlines of your maxillary arch and mandibular arch should align with the middle of your face. When this doesn’t happen, the condition is called a deviated midline.

When the upper right central incisor is shifted to the right then it   considered as upper midline shift towards right.

When the upper left central incisor is shifted to the left then it considered as upper midline shift towards left .When the lower right central incisor is shifted to the right then it considered as lower midline shift towards right.

When the lower right central incisor is shifted to the left then it considered as lower midline shift towards left.

The patient’s facial symmetry is examined to determine disproportions of the face in transverse and vertical planes.in most people the right and left sides are not identical. Thus some degree of asymmetry is considered normal.

Asymmetries that are gross and are detected easily should be recorded. Gross facial asymmetries can occur as a result of congenital defects, hemi-facial atrophy, unilateral condylar ankyloses and hyperplasia.

Facial profile – The facial profile is examined by viewing the patient from side. The facial profile helps in diagnosing gross deviation in the maxilla- mandibular relationship. The profile is assessed by joining the following two reference lines:

A line joining the forehead and the soft tissue point a (deepest point in curvature of upper lip a line joining point A and the soft tissue pogonion (most anterior point of the chin)

Based on the relationship between these two lines, three types of profiles exist-

Straight profile- The two lines form a nearly straight line.

Convex profile- The two lines form an angle with the concavity facing the tissue. This kind of profile can occurs as result of prognathic maxilla or a retro gnathic mandible as seen in a class 2, division 1 malocclusion.

Concave profile- The two reference lines form an angle with the convexity towards the tissue. This type of profile is associated with a prognathic mandible or a retro gnathic maxilla as in class 3 malocclusion.

Incompetent lips: They are morphological short lips that do not form a lip seal in a relaxed state. The lip seal can only complete by active contraction of the perioral and mentalis muscles.

 Lip incompetence can result in changes in facial development, tooth eruption & alignment, breathing, swallowing and jaw joint function.

Facial development: lip incompetence limits forward growth and increases vertical growth of face and dental arches leading to a long face, narrow arches, gummy smile, and recessed chin.

 Tooth eruption and alignment: teeth continue to erupt until they are in occlusion when teeth meet together. With lip incompetence, teeth and maxillary and mandibular arches lack adequate guidance from the occlusion, tongue position and orofacial muscle function. This leads to narrow arches, crowded teeth, and open bite & this can be correct by aligners.  

 Due to short upper lip gummy smile seen and it’s defined as continuous band of gingival display of more than 3mm, during spontaneous smile & lip repositioning is alternative cosmetic treatment for gummy smile.  

Prominent chin – The lower teeth and jaw project further forward than the upper and jaws. There is concave appearance in profile with the prominent chin.

 Prominent chin can cause under- bite, malocclusion of teeth     which cause biting, chewing, talking.

Depending on the cause and severity of large chin, surgery like chin reduction, osseous genioplasty   may require to correct problem & Aligner to fix under-bite.  

 Recessive chin - Retrogenia is a condition that occurs when your chin projects slightly backward toward your neck. This feature is also called a recessive chin.

 Implication of recessive chin:

• Difficult chewing

• Poor bite and tooth alignment

• Chronic jaw or joint (TMJ) pain and other issues with joints

• Difficulty in breathing especially during sleep

 Treatment of recessive chin is chin implant is a medical device made of silicon rubber that strengthens   the   jawline and reduces the appearance of recessive chin.

Chin surgery such as a sliding genioplasty enhances the projection of a receding chin by cutting the jawbone and moving it forward. Along with surgery overbite can correct by aligner.

It is the angle formed between the lower border of the nose and a line connecting the intersection of nose and upper lip with the tip of lip (labrale superius). This angle is normally 110 degree.

It reduces in patients having proclined upper anterior or prognathic maxilla & it increases in patients with retro gnathic maxilla or retro lined maxillary anterior.

When nasolabial angle is over 130 degrees, the nasolabial angle is described as being obtuse & in such case it should be considered as extraction case.

When nasolabial angle is 90 degrees or less is described as an acute nasolabial angle & it should be considered as non-extraction case.