A Tale of Two Treatment Options

Introduction

This case highlights the intricacies of combining cosmetic dentistry, airway-focused practice, and modern orthodontic solutions like clear aligners. It's fascinating how CandidPro's materials and technology can treat with far fewer attachments than other clear aligner systems and how technology like CandidMonitoring can enhance patient engagement and compliance, potentially leading to better outcomes and patient satisfaction.

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Initial dentition and diagnosis

A new patient entered my practice with a long-standing desire to address several cosmetic issues surrounding her front teeth. The patient was a 39-year old female presenting with a diastema and generalized spacing in her upper arch. The lower arch had mild lingual crowding and mild spacing. Failing restorations were present in both arches. (Figure 1).  X-rays reveal dilacerations of #13 and #27 with a large Taiwanese implant rendering #19 immobile. (Figure 2).

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As an airway-centric practitioner, I administer additional screening tools when I see signs or symptoms of potential airway disturbances. This patient had a very small mouth with small lateral incisors and narrow arches. Upon further examination, I observed a Class IV Friedman tongue position and Class IV Modified Mallampati score (Table 1, Figures 3A and 3B). The patient also had a Type III Tongue Tie (Figure 3C). I discussed the airway concerns I observed and recommended a cone-beam computed tomography scan (CBCT) to further evaluate her airway. 

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The patient consented, acknowledging that she did have a history of snoring. Upon evaluation of the CBCT image, it was apparent there was a restriction to her upper airway (Figure 4). The volumetric rendering highlighted the minimum area to be 147.7mm², which represents mild obstruction of the oropharynx.  

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When evaluating airway I utilize multiple screening tools and techniques, as test results can vary based on technique and/or patient position simply due to the soft tissue nature of these observations. While the CBCT indicates a constricted soft palate with mild airway obstruction, the Friedman and Mallampati classifications highlight a greater risk. 

When combined with the self-reported snoring, the use of airway-friendly principles and treatment techniques is certainly justified in the planning and presentation of potential treatment options. I offered a referral for medical evaluation and suggested a sleep study to gather additional data to support or refute airway concerns. She agreed to participate in a sleep study, but declined referral to a medical specialist. 

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The sleep study was completed the following evening using the Zmachine^Ⓡ Synergy, (General Sleep Corporation, Cleveland, OH, USA) (Table 2). Upon review of the sleep study data it became apparent that she was experiencing multiple oxygen desaturation events leading to abnormally low oxygen saturation levels. In addition, she showed a below normal level of time in REM sleep state. Her AHI, RDI and SE scores were within normal range.  

Looking at the diagnostic data in totality including; arch form and width, tongue size and position, CBCT volumetric reading, desaturation and REM stage data in addition to self-reported snoring, my diagnosis is upper airway resistance syndrome (UARS).

After reviewing the data we discussed multiple treatment options, each with different timelines, costs, and patient responsibilities. She elected to not address the failing restorations at this time and to straighten her teeth first using the clear aligner technique. As a standard practice I always bring up retention at the beginning of treatment. She preferred clear retainers over bonded lingual or Hawley retainers. We also discussed that once her final retainers are ordered they may no longer fit if she has new restorative work done at a later date.     

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Treatment planning

As part of my normal comprehensive records taking, I had already obtained a digital intraoral scan (Figure 5). Occlusal heatmap indicates fairly evenly distributed occlusal forces, with some premature occlusal contact across the anterior incisors. Since my patient was not committed to a specific brand of clear aligner, I decided to submit the case to two different manufacturers to see if there were any differences between default treatment plan setups based on the same instructions, scans, and preferences. 

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I submitted the case to CandidPro and a competing aligner system that I have used for many years. Instructions provided were to address the patient's chief complaint by closing the diastema. I also indicated that I would like expansive airway-friendly mechanics as opposed to closing the spaces through conventional retractive techniques. I flagged tooth #19 as an implant, so no movement would be programmed on this tooth. Both companies returned treatment plans in a timely manner.  

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As we can see above, the treatment plans came back looking quite different. (Figures 6 and 7).  The CandidPro system had not planned for any attachments, whereas the competing aligner system included 19 attachments in this treatment plan. I have become accustomed to seeing this many attachments in my treatment plans over the years. It still surprises me when I get my treatment plans back from CandidPro with few to no attachments planned. 

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To clarify, the CandidPro system offers attachments and will include them where needed, but the majority of my cases have very few to none. As I understand it, this is based on multiple factors,  including the elevated trimline providing enhanced structural rigidity as compared to a scalloped cut system. This design is then paired with a modern tri-layer plastic designed to maintain clinical force for extended periods, allowing gentle, continuous movements. 

Additionally, CandidPro has advanced beyond vacuum thermoforming techniques and implemented a proprietary positive-pressure thermoforming protocol, which allows each aligner to achieve intimate contact in the gingival embrasures to deliver accurate clinical forces closer to the center of rotation. While this reduced need for attachments is always fantastic news for patients, it significantly shortens or eliminates the need for lengthy aligner insertion visits, making the CandidPro workflow much more efficient for my practice. 

I presented both treatment options to my patient. She elected to go with CandidPro based on not wanting attachments, but she was also very interested in the CandidMonitoring™ aspect. As a busy professional, she said she definitely preferred to submit scans from home rather than committing to office visits for periodic aligner checks and clinical oversight of her treatment progress. 

Something that caught my eye when comparing these plans side-by-side was that in the non-CandidPro case, tooth #19 appeared to have some movement programmed despite being an implant (Figures 2 and 7). My concern is not that the implant will move, as it cannot. Implants do not possess a periodontal ligament, which is required to trigger the inflammatory catabolic bone remodeling response when compressed by orthodontic force. This is what allows both vital and non-vital teeth to move. My concern was the movements of the rest of the teeth in that arch may not track as planned if the immobile implant was programmed to move. This was a clear example of the value of having US licensed orthodontists providing oversight during the treatment planning process, as this implant was clearly missed by the other company.

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Tracking the progress of this case in treatment

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As we can see in the CandidMonitoring™ dashboard (Figure 8), the patient submitted all of her scans on schedule, indicating excellent engagement and compliance with my treatment instructions. At each stage CandidMonitoring AI detected that all programmed movements had been adequately expressed according to my treatment plan. My prescription pre-authorizes advancing to the next stage when tracking is detected, and requires I be notified of any deviations to my plan in terms of tracking or detected oral health conditions. There were no deviations, therefore at each stage, she received a “Go” notification in CandidApp: the patient-facing element of the CandidMonitoring system. 

The patient completed her full series of aligners with 100% remote monitoring (Figures 9-11). She was so happy with her straight teeth that upon return to the practice, she had already decided on, and budgeted for, replacing her old restorations before getting fitted for a retainer (Table 4).

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This is not unique to this case and is something I’ve experienced more with CandidPro than any other aligner system. It is my belief that this spontaneous desire to complete additional restorative treatment is the result of seeing so much improvement based on such little effort. My CandidPro patients have frequently been less hesitant to proceed with additional, often much-needed treatments. Again, in my opinion, this is likely because they haven’t “hit the wall” with aligner fatigue stemming from multiple refinements and so many appointments common with the other systems I have used. 

Another contributing factor leading to additional elective post-orthodontic restorative work is that I always discuss retention during the initial consultation. Retention is the most important phase of orthodontic treatment, and I want my patients to think about it from the beginning. It is important for them to know that if they invest in a retainer package, future restorative work may result in their retainers no longer fitting properly. This means they will have to immediately order new retainers and throw out any remaining from the previous order. Therefore it makes sense to budget for, and complete, any potential restorative work before ordering a multi-retainer package.

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Conclusion

In full disclosure, I am faculty at Candid Academy. I don’t just teach airway-friendly treatment techniques, I learn them from a tremendous network of orthodontic specialists and clear aligner instructors on staff at Candid. As an airway-centric provider, I feel fortunate to have access to the tools, training and expertise CandidPro provides. For example, I encourage you to go back and review the pre-treatment position of tooth #21 in Figure 1. Then review the programmed movement in Figure 7. Finally, take note of the final tooth position in Figure 9. This challenging rotation of a cylindrically shaped bicuspid occurring with predictability, and without attachments, IPR or refinements is uncommon with other clear aligner systems I’ve used. It is a testament to state of the art manufacturing, materials, mechanics and monitoring all coming together to allow me to prescribe CandidPro with confidence.

This patient could have been treated down two very different paths. One path may have omitted some, or all of the airway screening tests. It may have been treated with a retractive treatment plan including IPR further compounding the pre-existing, but unrecognized airway concerns. It may have had movement planned on an implant resulting in tracking issues and refinements. Instead, the path chosen looked beyond the teeth, and included systemic impacts of the oral cavity on the whole body. It included expert mechanics reviewed and refined by an orthodontic specialist. All amalgam was removed, and a healthy, expansive, equilibrated occlusion is in retention.

This comprehensive, airway-focused, orthodontic treatment was efficiently completed in a total of five visits to include; initial consult, review of sleep study results, review of treatment plans, aligner delivery and final records.

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