Dora Morocz is an orthodontic and clinical mentor for the Aligner Dental Academy. Here she shares her top tips on orthodontic treatment, including overcrowding and the most useful tools.
In the forum, we receive thousands of questions about orthodontic treatment and I have noticed that some issues are coming repeatedly. One of the most commonly discussed areas is the crowds and how to effectively create space.
Tips on crowding
Invisalign is an excellent tool for the treatment of crowding, but careful design is essential. Following are basic estimates when managing these cases.
1. Spacem
To resolve the overcrowding, space must be created. The selected method depends on the patient and a detailed safe evaluation. A secure evaluation provides a comprehensive evaluation of your patient, taking into account aesthetics, function, structure and biology. Discover more about safe evaluation here.
Before deciding on an approach, I always examine the goals of treatment, the patient’s original position, periodontal estimates such as bone loss and existing recession and if they had previously orthodontic treatment with IPR (interdisciplinary reduction).
2. IPR
Interdisciplinary reduction is a safe and effective way to create space between teeth. It can be done using strips, burs or disks. If you are looking for further ideas I highly recommend checking it Dr. Raman Aulakh Ted Talk on IPR.
Time is critical. If you try to run the IPR very early when there is still crowds, access to contacts can be difficult. Instead, you can delay the IPR at a later stage when the teeth are better aligned. Remember, however, that this is essentially round, so make sure your patient has the gum biotechnics and bone support to handle temporary expansion.
3. Extension
Expanding the shape of the arch can also create space, but it is important to differentiate the rotation uniform and the physical movement of the teeth. Excessive expansion can lead to recession, so I always carefully evaluate the biotechnical and reduce expansion if needed. While up to 2 mm extension per side is generally predictable, whether it is safe depends on the individual patient.
4. Elimination
For moderate to severe overcrowding, removing a lower central cutter (about 5.5mm wide) can sometimes be a better alternative to excessive IPR or extension. Carefully evaluate the angle of teeth on each side of the cutter you intend to export – Ideally you would like to converge the roots so that you can benefit from the overthrow of the middle crown when closing the space.
Consequences of crowding resolution
When solving the overcrowding, there are some important factors that you should keep in mind:
- Black triangles: If the teeth are triangular or overlapping, their alignment can lead to black triangles. I always make sure to show patients photos of possible results so that they can understand what can happen. If needed, black triangles can be minimized by IPR or resolved by rehabilitation techniques after treatment
- Risk of recession: Expansion increases the risk of recession, so I closely monitor patients undergoing extension and make sure you include this risk when they pass through consent before treatment
- Round: This happens when the anterior teeth temporarily move forward to make IPR space before moving back. While the round impact may be useful in some cases, it is not ideal for patients with recession or thin biotechnics.
Using Clincheck tools
Clincheck tools are invaluable in planning and refining treatment. I recommend using the superiority tool to visualize the predictability of motion and to check the tooth movement table to evaluate feasibility. In case of doubt, I create multiple clinically – one with maximum IPR and extension, and another taking into account a lower cutter export – to compare different approaches.
This also helps patients understand their choices during the consent process.
Do you have more questions?
I hope you found this information useful. If you have any further questions, I encourage you to deal with our Expert Community in the Aligner Dental Academy (ADA) forum. As a member of ADA, you have access to rich knowledge and discussions in real world.
Whether you need tips on a particular case, the design information or guidance on treatment approaches, the forum is the perfect place to ask for support and share your experiences. I am looking forward to seeing your questions and continuing the conversation!
Find more information on integration at the Aligner Dental Academy here.
This article is funded by the Aligner Dental Academy.
